Traumatic head injuries that are associated with labor or delivery can be external and obvious, such as a skull or mandibular fracture; they can be intracranial; and in some, they are covert. The fetal head has considerable plasticity and can undergo appreciable molding. Rarely, severe molding can result in tearing of veins. hese may be the bridging cortical veins that empty into the sagittal sinus, the internal cerebral veins, the vein of Galen, or those of the tentorium itself. As a result, intracranial, subdural, and even epidural hemorrhage can be seen after an apparently uneventful vaginal delivery (Scheibl, 2012). Bleeding may also be asymptomatic. Conversely, subgaleal hemorrhages associated with forceps of vacuum delivery can be life threatening (Doumouchtsis, 2008; Swanson, 2012). In rare severe head trauma cases, fetal brain tissue can embolize to the heart or lungs (Cox, 2009).
Most aspects of neonatal intracranial hemorrhage are related to gestational age. Speciically, most hemorrhage in the preterm neonate results from hypoxia and ischemia. However, in term newborns, trauma is the most frequent cause. Some varieties are shown in Table 33-5. Importanty, in some newborns, a putative cause is not ound. Intracranial hemorrhage is asymptomatic in many cases. The reported incidence varies, but it is highest with operative deliveries-both vaginal and cesarean deliveries. In the study by Moczygemba and colleagues (2010), for more than 8 million singleton deliveries, the overall intracranial hemorrhage rate approximated 0.2 per 1000 births. In another study, Werner and associates (201rl) cited a combined incidence in more than 120,000 nulliparous singleton operative deliveries of 0.12 percent, or about 1 in 750 procedures. he rates of intracranial hemorrhage were 1 :385 with vacuum delive)a; 1: 515 with forceps, and 1: 1210 with cesarean delivery. In another study, its incidence was nearly 1 percent following vacuum-assisted deliveries (Simonson, 2007).
According to the American College of Obstetricians and Gynecologists (2015), the incidence of intracranial hemorrhage from birth trauma has been substantively lowered by elimination of diicult instrumented vaginal deliveries. This was veriied in a report of carefully conducted Kielland forceps deliveries (Burke, 2012).
The prognosis after hemorrhage depends on its location and extent (see Table 33-5). For example, subdural and subarachnoid hemorrhage seldom results in neurological abnormalities, whereas large hematomas are serious. Any bleeding into the parenchyma from intraventricular or intracerebellar hemorrhage often causes serious permanent damage or death. Periventricular hemorrhage rarely causes the type of sequelae that are common in those born preterm (Chap. 34, p. 639).
Newborns who have traumatic subdural or infratentorial hemorrhage tears will have neurological abnormalities from the time of birth (Volpe, 1995). Those most severely afected have stupor or coma, nuchal rigidity, and opisthotonos that worsen over minutes to hours. Some newborns who are born depressed appear to improve until about 12 hours of age, when drowsiness, apathy, feeble cry, pallor, failure to nurse, dyspnea, cyanosis, vomiting, and convulsions become evident.