Fetal and Neonatal Care

Birth injuries: brachial plexus palsy, cephalohematoma, caput succedaneum

Clinical Overview and When to Suspect

Birth injuries encompass mechanical trauma sustained during labor and delivery. Three high-yield entities for the ABP exam are brachial plexus palsy (BPP), cephalohematoma, and caput succedaneum.

— Macrosomia (birth weight >4,000 g, especially >4,500 g)

— Shoulder dystocia

— Prolonged or difficult labor

— Instrumental delivery (vacuum, forceps)

— Breech presentation (especially BPP)

Incidence: birth trauma occurs in ~6–8 per 1,000 live births; most injuries are mild and self-limited

Risk factors common to all three:

Board pearl: The ABP loves to test the DISTINCTION between cephalohematoma and caput succedaneum — know the anatomic layer where blood/fluid collects and how that determines whether swelling crosses suture lines

When to suspect BPP: asymmetric Moro reflex, arm held in abnormal posture, lack of spontaneous movement of one upper extremity noted in the delivery room or nursery exam

When to suspect cephalohematoma vs caput: any scalp swelling in the newborn — the key is the timing, location, and whether it crosses suture lines

History — Risk Factor Identification and Birth Narrative

A detailed birth history is essential when evaluating any suspected birth injury:

— Shoulder dystocia: documented? Maneuvers used (McRoberts, suprapubic pressure, delivery of posterior arm)?

— Instrumentation: vacuum (associated with cephalohematoma, subgaleal hemorrhage), forceps (bruising, facial nerve palsy, cephalohematoma)

Maternal history: gestational diabetes (→ macrosomia), prior macrosomic infant, prior birth injury, multiparity, maternal obesity, prolonged pregnancy (≥42 weeks)

Labor history: prolonged second stage, oxytocin augmentation, precipitous delivery, abnormal fetal presentation

Delivery details:

Birth weight and head circumference

Apgar scores and need for resuscitation (may coexist with asphyxia)

Board pearl: Shoulder dystocia is the single strongest risk factor for BPP, but ~50% of BPP cases occur WITHOUT documented shoulder dystocia — can also result from intrauterine positioning or breech extraction

Family history: connective tissue disorders (rarely) may predispose to nerve stretch injury

Physical Exam Findings — Distinguishing the Three Entities

— Soft, boggy, superficial swelling of the scalp

— Located ABOVE the periosteum in the subcutaneous tissue

— CROSSES suture lines — this is the defining feature

— Present at birth, often over the presenting part

— May have overlying ecchymosis or petechiae

— Resolves spontaneously within 24–48 hours

— Subperiosteal hemorrhage — blood collects between periosteum and skull bone

— Does NOT cross suture lines — confined to one cranial bone (most commonly parietal)

— May NOT be present at birth — appears hours after delivery and enlarges over first 24–48 hours

— Firm, fluctuant, well-circumscribed

— Can calcify if large; may take weeks to months to resolve

— Asymmetric posture/movement of the upper extremities

— Erb palsy (C5–C6): "waiter's tip" — arm adducted, internally rotated, forearm pronated, wrist flexed; absent Moro on affected side

— Klumpke palsy (C8–T1): rare; "claw hand," absent grasp reflex, ± ipsilateral Horner syndrome

— Total plexus palsy (C5–T1): flaccid arm, no movement

Board pearl: Asymmetric Moro reflex is the classic exam clue for BPP on board questions

Caput succedaneum:

Cephalohematoma:

Brachial plexus palsy:

Diagnostic Workup — Cephalohematoma and Caput Succedaneum

— Diagnosis is CLINICAL — no imaging or labs needed

— If extensive bruising → monitor for indirect hyperbilirubinemia (↑ bilirubin from resorption of extravasated blood)

— Diagnosis is usually clinical based on characteristic exam (does not cross sutures, appears after birth)

— Imaging: skull radiograph or CT ONLY if fracture suspected (underlying linear skull fracture present in ~5–18% of cephalohematomas)

— Labs: monitor transcutaneous or serum bilirubin — cephalohematomas are a significant risk factor for neonatal hyperbilirubinemia

— CBC if very large → may contribute to anemia

— Board pearl: Do NOT aspirate a cephalohematoma — risk of introducing infection far outweighs any benefit; allow spontaneous resorption

— Subgaleal hemorrhage: blood beneath the aponeurosis → diffuse, fluctuant swelling that CROSSES suture lines AND increases in size

— Unlike caput, subgaleal hemorrhage is progressive and can cause hypovolemic shock

— Associated with vacuum-assisted delivery

— Requires urgent volume resuscitation and monitoring

Caput succedaneum:

Cephalohematoma:

Key distinction from subgaleal hemorrhage (a true emergency):

Diagnostic Workup — Brachial Plexus Palsy

— Test each muscle group: deltoid (C5), biceps (C5–C6), wrist extensors (C6–C7), finger extensors (C7), hand intrinsics (C8–T1)

— Check Moro, biceps, grasp reflexes bilaterally

— Assess for Horner syndrome (ptosis, miosis, anhidrosis) → suggests C8–T1 involvement or avulsion

— Ipsilateral clavicle fracture (palpate for crepitus, tenderness, step-off) — most commonly associated fracture

— Humeral fracture — swelling, pseudoparalysis

— Phrenic nerve palsy (C3–C5) → ipsilateral diaphragm paralysis → tachypnea, asymmetric chest rise

— X-ray of clavicle and humerus to exclude fracture

— Chest X-ray if respiratory distress → elevated hemidiaphragm suggests phrenic nerve injury

— MRI of brachial plexus if no improvement by 1–3 months → evaluate for nerve root avulsion

— EMG/nerve conduction studies at 3–4 weeks if needed to assess severity (denervation potentials)

Initial diagnosis is clinical — based on characteristic posture and asymmetric movement/reflexes

Detailed neurologic exam of the affected extremity:

Rule out associated injuries:

Imaging:

Board pearl: Clavicle fracture alone can mimic BPP (pseudoparalysis) — but Moro reflex is typically intact with isolated clavicle fracture; the hand grasp is preserved in both Erb palsy and clavicle fracture

Management — Caput Succedaneum and Cephalohematoma

— Reassurance — resolves within 24–72 hours

— No intervention needed

— Monitor bilirubin only if significant bruising coexists

— Observation — most resolve over 2 weeks to 3 months

— Do NOT aspirate, incise, or apply pressure bandages

— Monitor for jaundice: bilirubin check per hour-specific nomogram; earlier phototherapy threshold may apply because cephalohematoma is a risk factor for significant hyperbilirubinemia

— Monitor head circumference serially — enlarging swelling raises concern for re-bleeding or underlying fracture

— Large cephalohematomas → CBC to assess for anemia; rare need for transfusion

— Calcification may occur, creating a hard, bony ridge that can persist for months but eventually remodels

— Board pearl: The ABP frequently tests that cephalohematoma is a risk factor for hyperbilirubinemia requiring phototherapy — especially in combination with other risk factors (prematurity, ABO incompatibility, G6PD deficiency)

Caput succedaneum:

Cephalohematoma:

Management — Brachial Plexus Palsy: Initial Approach

— Gentle handling of the affected arm

— Avoid traction on the limb

— Pin the sleeve to the shirt or gentle immobilization in a neutral position for the first 1–2 weeks to reduce pain and further stretching

— Parents should be taught passive range-of-motion (ROM) exercises starting at ~2–3 weeks of age to prevent joint contractures

— Begin formal PT by 2–4 weeks of life

— Focus on passive ROM (shoulder abduction, external rotation, forearm supination) to maintain joint mobility

— Active-assisted exercises as reinnervation occurs

— Frequent reassessment in first 3 months: serial exam tracking biceps function recovery

— If biceps function does not recover by 3–6 months → refer to a pediatric nerve/hand surgeon for consideration of microsurgical repair

Vast majority (70–92%) of BPP cases resolve spontaneously, especially upper trunk (Erb) palsies

Initial management — supportive and preventive:

Physical therapy referral: key intervention

Follow-up schedule:

Board pearl: The most important prognostic indicator is return of biceps function by 3 months of age → predicts excellent spontaneous recovery

Management — Brachial Plexus Palsy: Surgical and Long-Term

— No biceps recovery by 3–6 months (depending on center)

— Total plexus palsy with Horner syndrome (suggests root avulsion → less likely to recover spontaneously)

— Evidence of nerve root avulsion on MRI

— Nerve grafting (sural nerve graft to bridge gap)

— Neurolysis (release of scar tissue)

— Nerve transfer (redirect functioning nerve to denervated muscle)

— Secondary procedures: tendon transfers, osteotomies for persistent contractures or skeletal deformity (posterior shoulder subluxation)

— Shoulder dysplasia and posterior subluxation/dislocation (from muscle imbalance → internal rotation contracture)

— Limb-length discrepancy (affected arm shorter)

— Reduced strength and ROM even after recovery

— Psychosocial impact: body image, functional limitations in childhood activities

Surgical indications:

Surgical options:

Long-term complications of BPP:

Board pearl: Even infants with "recovered" BPP may have subtle residual deficits — ongoing developmental and orthopedic follow-up is important through childhood

Age-Specific Considerations — Neonatal Period

— Bilirubin risk peaks at 3–5 days as the hematoma is resorbed → ensure close outpatient follow-up for jaundice if early discharge

— Newborn exam: asymmetric Moro is the most reliable clue; asymmetric tonic neck reflex may also be absent

— Pain may cause pseudoparalysis → differentiate from true nerve injury by observing over days as pain subsides

— Must rule out clavicle and humeral fractures in the first 24–48 hours

— Early parental counseling is essential: most cases recover, but set expectations for close follow-up

Caput succedaneum is most prominent immediately after birth and resolves in the first 1–3 days → by the time of the nursery discharge exam (24–48 hours), it is often nearly gone

Cephalohematoma may NOT be apparent in the first hours → the classic board scenario: swelling absent at initial exam, appears and grows over 12–24 hours, firm and does not cross sutures

BPP in the neonate:

Board pearl: A well-appearing newborn with isolated caput succedaneum does NOT need imaging or extended observation — it is benign

Age-Specific Considerations — Infant and Beyond

— By 2–4 weeks: may feel firm/calcified at edges with soft center → parents may worry about a "dent" in the skull → reassure that this is normal remodeling and resolves by 3–6 months

— Rarely: organized cephalohematoma persists → may require surgical correction for cosmesis if very large, though this is uncommon

— Late-presenting anemia or prolonged jaundice → consider unresolved cephalohematoma or coagulopathy

— 1–3 months: most upper trunk injuries show progressive recovery; absence of biceps function is concerning

— 3–6 months: decision window for surgical referral

— 6–12 months: secondary shoulder contractures may begin → monitor with serial ROM measurement

— Toddler/preschool: children adapt remarkably; occupational therapy focuses on functional activities, fine motor, and bilateral coordination

— School age: may have persistent internal rotation contracture, supination deficit → affects activities (reaching overhead, carrying, sports)

Cephalohematoma:

Brachial plexus palsy across infancy:

Board pearl: Persistent Erb palsy beyond infancy often manifests as internal rotation posture of the shoulder and forearm pronation, leading to functional limitations rather than complete paralysis

Complications and Emergencies — Scalp Injuries

— Rarely significant; overlying skin breakdown (from prolonged pressure or vacuum) → infection risk

— Extensive caput with ecchymosis → ↑ bilirubin load → watch for severe hyperbilirubinemia

— Hyperbilirubinemia: the most common and testable complication; breakdown of trapped RBCs → ↑ unconjugated bilirubin

— Anemia: large hematomas can sequester significant blood volume

— Infection: extremely rare but can occur → presents as enlarging, warm, erythematous swelling with fever → aspirate ONLY if infection suspected, send for culture

— Underlying skull fracture: typically linear, non-displaced → usually no treatment needed; depressed fractures rare

— Calcification: cosmetic concern; remodels over months

— This is the emergency that must NOT be missed

— Blood accumulates in the potential space beneath the galea aponeurotica → can hold the neonate's ENTIRE blood volume

— Signs: progressive, fluctuant boggy swelling crossing sutures, ↑ head circumference, pallor, tachycardia, hypotension

— Management: emergent volume resuscitation, blood products, NICU admission

— Board pearl: Vacuum delivery + progressive scalp swelling + hemodynamic instability = subgaleal hemorrhage until proven otherwise

Caput succedaneum complications:

Cephalohematoma complications:

Critical distinction — Subgaleal hemorrhage (SGH):

Complications and Emergencies — Brachial Plexus Palsy

— Clavicle fracture (most common associated injury, ~10% of BPP)

— Humeral fracture (less common)

— Phrenic nerve palsy (C3–C5): diaphragm paralysis → respiratory distress, elevated hemidiaphragm on CXR; occurs in ~5% of BPP cases

— Facial nerve palsy: may coexist with difficult delivery

— Cervical spinal cord injury (very rare): suspect if bilateral upper extremity weakness or lower extremity involvement

— Respiratory distress with ipsilateral BPP → evaluate for phrenic nerve palsy (CXR → fluoroscopy/ultrasound of diaphragm)

— No improvement or worsening at 4–6 weeks → ensure correct diagnosis; consider alternative etiologies (fracture, CNS lesion)

— Total plexus palsy with Horner syndrome at birth → early neurosurgical/nerve specialist referral (high likelihood of avulsion)

Associated injuries to evaluate:

When to escalate care:

Board pearl: Phrenic nerve palsy causing respiratory distress in a neonate with ipsilateral BPP is a classic board scenario — CXR shows elevated hemidiaphragm on the affected side; confirmed by fluoroscopy or ultrasound showing paradoxical diaphragm movement

Key Differentials — Scalp Swelling in the Newborn

• The ABP expects you to distinguish these entities by anatomy and clinical features:
Feature	Caput	Cephalohematoma	Subgaleal hemorrhage
• Layer: Caput → subcutaneous/above periosteum; Cephalohematoma → subperiosteal; Subgaleal → sub-aponeurotic
• Crosses sutures: Caput → YES; Cephalohematoma → NO; Subgaleal → YES
• Timing: Caput → present at birth, resolves quickly; Cephalohematoma → appears after birth, enlarges over hours; Subgaleal → progressive, relentless
• Consistency: Caput → soft, pitting; Cephalohematoma → firm, fluctuant; Subgaleal → boggy, diffuse, ballotable
• Hemodynamic impact: Caput → none; Cephalohematoma → rare mild anemia; Subgaleal → potentially catastrophic hemorrhage
• Other differentials for scalp swelling:
— Craniosynostosis (ridging along sutures, abnormal head shape)
— Dermoid cyst (midline or lateral, non-tender, present from birth but doesn't change rapidly)
— Encephalocele (midline defect, transilluminates, covered by skin)
• Board pearl: If a scalp swelling crosses suture lines AND is getting bigger → it is NOT a cephalohematoma; consider caput (resolving) vs subgaleal hemorrhage (expanding → emergency)

Key Differentials — Asymmetric Arm Movement in the Newborn

— Pseudoparalysis from pain → infant does not move arm

— Moro reflex: typically INTACT once pain subsides (vs absent in BPP)

— Palpable crepitus/irregularity over clavicle

— X-ray confirms fracture; greenstick fractures may be subtle initially

— Swelling, tenderness of the arm

— Moro reflex absent on affected side (similar to BPP)

— X-ray differentiates

— Onset typically after first 48 hours (not immediately at birth)

— Fever, irritability, swelling, erythema around joint

— Labs: ↑ CRP, ↑ WBC; blood culture, joint aspiration

— Usually bilateral or involves lower extremities as well

— Altered sensorium, seizures may be present

— Tone abnormalities beyond a single nerve distribution

Brachial plexus palsy vs other causes of asymmetric upper extremity movement:

Clavicle fracture:

Humeral fracture:

Septic arthritis/osteomyelitis of the shoulder:

CNS injury (stroke, intracranial hemorrhage):

Board pearl: Asymmetric Moro + normal clavicle X-ray = brachial plexus palsy; Asymmetric Moro + clavicle fracture on X-ray = could be BOTH (they commonly coexist — reassess after fracture heals to determine if BPP is also present)

Preventive Care and Screening

— Accurate estimation of fetal weight (clinical + ultrasound)

— Planned cesarean delivery may be discussed for estimated fetal weight >5,000 g (non-diabetic) or >4,500 g (diabetic mother)

— Appropriate management of shoulder dystocia with established maneuvers

— ALL newborns should have a complete physical exam within 24 hours including assessment of clavicles, extremity movement, Moro reflex symmetry, and scalp/head exam

— Document head circumference and scalp findings — repeat measurement before discharge if cephalohematoma present

— Universal pre-discharge bilirubin screening (transcutaneous or serum) — cephalohematoma is a recognized risk factor that lowers the threshold for follow-up

— Plot on hour-specific nomogram

— Ensure outpatient follow-up within 24–48 hours of discharge for bilirubin recheck if in intermediate or high-risk zone

Prevention of birth injuries begins with obstetric risk assessment:

Screening in the nursery:

Bilirubin screening:

Board pearl: On the ABP exam, a newborn with cephalohematoma + another risk factor for hyperbilirubinemia (e.g., ABO incompatibility, prematurity, East Asian ethnicity, exclusive breastfeeding) should have LOWER threshold for phototherapy and closer follow-up

Follow-Up and Anticipatory Guidance

— No specific follow-up needed beyond routine newborn care

— Reassure parents it is temporary and benign

— Outpatient bilirubin recheck within 24–48 hours of discharge

— Recheck head circumference at 2-week well visit — should be stable or decreasing

— Counsel parents: the mass may feel firm/calcified at 2–4 weeks → this is normal; it will remodel and flatten over weeks to months

— If swelling increases or new symptoms develop (fever, expanding mass, increasing pallor) → return immediately

— 2-week visit: reassess motor function, start gentle ROM exercises at home

— Monthly neurovascular reassessment for first 3 months

— PT referral by 2–4 weeks

— Critical milestone: biceps function recovery by 3 months → if absent, refer to specialist

— Educate parents on home ROM exercises: passive shoulder abduction, external rotation, elbow flexion/extension, forearm supination — performed gently during diaper changes and play

Caput succedaneum:

Cephalohematoma:

Brachial plexus palsy:

Board pearl: The general pediatrician's most important role in BPP is ensuring timely referral — missing the surgical window (3–6 months) can result in worse outcomes

Family Counseling and Psychosocial Considerations

— Parents may feel the injury was preventable or someone is "at fault"

— Provide empathetic, honest counseling: explain that birth injuries can occur even with optimal obstetric care

— Use clear language: avoid jargon; explain anatomy simply ("a collection of blood between the bone and its covering")

— Emphasize the favorable prognosis: >80% of Erb palsies recover fully or near-fully by 3–6 months

— Set realistic expectations: recovery is gradual; some infants recover in weeks, others in months

— Acknowledge parental frustration with the "wait and see" approach — frame it as active monitoring, not passive neglect

— Discuss that surgical options exist if recovery does not occur, and the timeline for those decisions

— Connect families with support groups (e.g., United Brachial Plexus Network)

— Reassure about the benign natural history

— Explain the jaundice risk and importance of bilirubin follow-up

— Warn about calcification phase so parents are not alarmed by the changing texture of the lump

Birth injuries often cause significant parental guilt and anxiety:

For brachial plexus palsy:

For cephalohematoma:

Board pearl: Effective family counseling and timely follow-up are core general pediatric competencies tested on the ABP exam — know the "what, why, and when" of reassurance vs referral

High-Yield Associations and Rapid-Fire Facts

Caput succedaneum: crosses sutures, present at birth, resolves in days, benign

Cephalohematoma: does NOT cross sutures, appears after birth, subperiosteal, risk of hyperbilirubinemia and anemia, underlying fracture in ~5–18%, do NOT aspirate, calcifies

Subgaleal hemorrhage: crosses sutures, sub-aponeurotic, EXPANDS, can be FATAL → emergency

Erb palsy (C5–C6): "waiter's tip," absent Moro on affected side, most common BPP

Klumpke palsy (C8–T1): "claw hand," absent grasp, ± Horner syndrome (ptosis + miosis + anhidrosis)

Total plexus palsy (C5–T1): flaccid arm, worst prognosis

Phrenic nerve palsy (C3–C5): elevated hemidiaphragm ipsilateral to BPP

Most important prognostic factor in BPP → return of biceps function by 3 months

Surgical referral window → 3–6 months if no recovery

Shoulder dystocia → strongest single risk factor for BPP

Vacuum delivery → strongest association with subgaleal hemorrhage and cephalohematoma

Cephalohematoma + jaundice risk factors = lower phototherapy threshold

Board pearl: The ABP tests anatomy (which layer), clinical distinction (sutures or not), and management (observe vs intervene) — not obstetric technique

One-Line Recap

Birth injuries tested on the ABP center on three entities — caput succedaneum (subcutaneous, crosses sutures, present at birth, benign, resolves in days), cephalohematoma (subperiosteal, does NOT cross sutures, appears after birth, monitor for hyperbilirubinemia/anemia, never aspirate, calcifies then remodels — and must be distinguished from life-threatening subgaleal hemorrhage which crosses sutures, expands relentlessly, and causes hypovolemic shock especially after vacuum delivery), and brachial plexus palsy (Erb C5–C6 "waiter's tip" is most common, Klumpke C8–T1 with Horner syndrome is rare but signals avulsion, diagnosis is clinical with asymmetric Moro reflex as the hallmark finding, rule out clavicle/humeral fracture and phrenic nerve palsy, manage with gentle ROM exercises and physical therapy, prognosis hinges on biceps recovery by 3 months, and surgical referral by 3–6 months if no improvement).

Board Question Stem Patterns

Newborn with scalp swelling that crosses suture lines, present at birth, soft and pitting → diagnosis: caput succedaneum → next step: reassurance, routine care

Newborn with firm scalp swelling over right parietal bone, noted at 12 hours, does not cross sutures → diagnosis: cephalohematoma → next step: monitor bilirubin, do NOT aspirate

Vacuum-assisted delivery, progressive diffuse scalp swelling, HR 190, pallor → diagnosis: subgaleal hemorrhage → next step: emergent volume resuscitation, NICU

Macrosomic infant, shoulder dystocia, right arm adducted/internally rotated, absent Moro on right → diagnosis: right Erb palsy (C5–C6) → next step: X-ray clavicle/humerus to rule out fracture, gentle handling, PT referral

Infant with BPP + ipsilateral ptosis and miosis → diagnosis: Klumpke palsy with Horner syndrome (C8–T1) → next step: MRI brachial plexus, early surgical referral

Infant with BPP + respiratory distress, CXR shows elevated right hemidiaphragm → diagnosis: associated phrenic nerve palsy → next step: confirm with diaphragm ultrasound

4-month-old with BPP, no biceps function → next step: referral to nerve/hand surgeon for microsurgical evaluation

Cephalohematoma at day 3 + ABO incompatibility + total serum bilirubin rising → next step: initiate phototherapy at lower threshold

Asymmetric Moro, palpable clavicle crepitus → next step: clavicle X-ray → manage fracture AND reassess for BPP once pain resolves

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