The clavicle is the bone most commonly fractured during labor and delivery. The fracture is usually of the "greenstick" variety, meaning that the fracture does not extend all the way through the bone. Crepitus and irregularity are present on palpation over the fracture. Active or passive movement of the arm is painful, and the Moro reflex is usually absent on the involved side. Therapy consists of immobilizing the arm and shoulder, usually for seven to 10 days, so as to minimize discomfort. Prognosis is excellent and complete healing should be expected in four to six weeks.
Skull fractures are uncommon and usually result from difficult delivery or forceps extraction. The fracture may be linear or depressed. Linear fractures are accompanied by soft tissue swelling. A depressed fracture usually results in a visible and palpable indentation. Most fractures are asymptomatic but fractures that are associated with the neurological symptoms may require surgical elevation of the depressed segment.
Petechiae found on the head, neck, chest, and back because of difficult delivery are not progressive. In contrast, petechiae resulting from hemorrhagic disorders are generally progressive and are distributed all over the body. Bruises and ecchymoses may also be seen after a difficult delivery. Hyperbilirubinemia may result from breakdown of the extravasated blood.
Cephalohematoma is a subperiosteal collection of blood resulting from traumatic rupture of blood vessels passing from the skull to the periosteum. Cephalohematoma is most common over the parietal bone and does not cross suture lines in contrast to the edema of caput succedaneum. Significant blood loss and a linear skull fracture may be associated with a cephalohematoma. Incision or aspiration of a cephalohematoma is contraindicated because of the risk of infection. By three to four days of age, the area is fluctuant and has a peripheral edge of organizing tissue. Most cephalohematoma are re-absorbed in two to three months.
Brachial plexus injury
Brachial plexus injury results from trauma to one or more of the spinal roots C5 to C8 during birth. The arm is held adducted with internal rotation, extension at the elbow, pronation of the forearm and flexion at the wrist.
Muscle tone is decreased and reflexes are absent. If the nerve roots are intact, most infants recover from this injury within three to six months. Physical therapy should be provided to maintain the range of motion.
Phrenic nerve paralysis
Hyperextension of the neck during delivery can result in phrenic nerve injury (C3 to C5) and diaphragmatic paralysis. The infant develops respiratory distress and often has an associated brachial plexus injury. Most infants recover spontaneously within two to 3 months.