Head Trauma After Instrumental Births

doi:10.1016/j.clp.2007.11.006

Clinics in Perinatology

Volume 35, Issue 1, March 2008, Pages 69-83

https://doi.org/10.1016/j.clp.2007.11.006 Get rights and content

Instrumental vaginal delivery involves the use of the vacuum extractor or obstetric forceps to facilitate delivery of the fetus. It is associated with substantial risk of head injury, including hemorrhage, fractures, and, rarely, brain damage or fetal death. This review article describes the different types, etiology, pathophysiology, risk factors, and clinical features of head trauma after instrumental birth, along with their management and prevention strategies.

Section snippets

Scalp bruises and lacerations

Infants delivered by vacuum extraction may sustain minor scalp injuries. Most of them are of no clinical significance. Bruising and vacuum marks resolve quickly without sequelae [8]. Most of the scalp abrasions and lacerations are superficial and minor in degree [9]. Scalp and face injuries occur on average in 16% of vacuum deliveries and 17% of forceps deliveries [10]. Alopecia due to vacuum-associated scalp trauma has been reported [11]. The incidence of scalp abrasions is higher in infants

Summary

Instrumental vaginal deliveries have risks of failure and complications. The obstetrician should critically appraise the indications for the procedure and the risk factors to provide a safe delivery for fetus and mother. Knowledge of the injuries that can be caused by improper use of vacuum and forceps is of paramount importance in the decision-making process.

The most appropriate intervention needs to be decided after consideration of the clinical circumstances as well as the operator's skills

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Cited by (47)

Depressed skull fracture presenting a cookie-cutter aspect with a Malmström ventouse: A case report and review of the literature
2023, Gynecologie Obstetrique Fertilite et Senologie
Skull fracture during instrumental delivery using spatulas: A case report with CT-scan imaging
2021, Journal of Gynecology Obstetrics and Human Reproduction
Citation Excerpt :
However, the association of skull fracture with intracranial lesions appears to be limited to instrumental deliveries only [7]. Fetal skull fractures are caused either by compression of the skull by the blades of forceps or by compression of the fetal head by the maternal pelvic bones [8]. Fractures are very rare with vacuum cups [7] and almost exclusively described with the Malmström cup [9].
The association between low birth weight and outcomes of vacuum assisted vaginal delivery
2021, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
Although vacuum-assisted vaginal delivery (VAVD) is generally considered safe, less is known about outcomes of VAVD in LBW. VAVD is a known risk factor for certain neonatal adverse outcomes, specifically those related to birth trauma (e.g cephalohematoma, subgaleal hematoma, intracranial hemorrhage, clavicular fractures, skull fractures and facial lacerations, and nerve damage) [4–10]. Prematurity (<34 weeks of gestation), is considered a relative contraindication to VAVD; however, guidelines do not specify a weight cutoff [11].
It is often hypothesized that poor neonatal outcomes are more frequently observed in low birth weight (LBW) neonates following vacuum assisted vaginal delivery (VAVD). We sought to assess the association between low birth weight (< 2500 g) and neonatal outcomes, following vacuum extraction.
This was a retrospective cohort study, including 1085 deliveries in a tertiary medical center between 2003 and 2015. Maternal and neonatal outcomes, including birth trauma related complications, were compared between women with singleton pregnancies beyond 34 weeks' gestation and fetal weight < 2500 g who were delivered by vacuum extraction (n=345) and a control group (n=740) with fetal weight ≥ 2500 g, matched in maternal age, parity and gestational week.
During the study period, 370 women met the inclusion criteria for the study group, with 25 cases eventually excluded due to missing neonatal birth trauma related data. 740 patients were included in the matched control group. Induction of labor and non-reassuring fetal heart rate as an indication for VAVD were more prevalent in the LBW group. The composite birth trauma related adverse outcome was higher in the control group (9.1 % vs. 4.4 %, p = 0.008), mainly due to increased rate of cephalohematoma in this group (6.8 % vs. 2.9 %, p = 0.01). All other adverse neonatal outcomes rates did not differ between the groups. Women in the control group were more prone to post-partum hemorrhage (p < 0.001), had more episiotomies (p = 0.004) and a higher failed VAVD rate (11.4 % vs. 2.6 %, p < 0.001), leading to emergency cesarean delivery. A sub-group analysis of failed VAVD did not reveal a difference in neonatal complications between the LBW and the control group.
Neonatal birth trauma and adverse outcomes following vacuum extraction are no more common in neonates weighing less than 2500 g than those with higher birth weights, even in failed vacuum cases.
Short-term neonatal outcomes of vacuum-assisted delivery. A case-control study
2019, Anales de Pediatria
El objetivo fue comparar la morbimortalidad neonatal de los partos vaginales por ventosa con los restantes partos vaginales e identificar los factores de riesgo.
Realizamos un estudio caso-control, retrospectivo, en un hospital con servicios de neonatología y cuidados intensivos neonatales, entre 2012 y 2016, con inclusión de 1.802 partos vaginales con ventosa, 1.802 partos eutócicos y 909 partos con fórceps. Se consideraron complicaciones menores (traumatismo de tejidos blandos, cefalohematoma, ictericia, fototerapia doble, lesión transitoria del plexo braquial) y mayores (encefalopatía hipóxico-isquémica, hemorragia intracraneal y subgaleal, convulsión, fractura craneal, lesión permanente del plexo braquial), ingreso en la Unidad de Cuidados Intensivos Neonatales y fallecimiento.
El riesgo de traumatismo de los tejidos blandos (ORa 2,4; p < 0,001), cefalohematoma (ORa 5,5; p < 0,001), ictericia (ORa 4,4; p < 0,001), fototerapia doble (ORa 2,1; p < 0,001) y lesión transitoria del plexo braquial (ORa 2,1; p = 0,006) fue mayor en los partos con ventosa en comparación con los eutócicos. El ingreso en la Unidad de Cuidados Intensivos Neonatales también fue mayor en los partos con ventosa que en los eutócicos (OR 1,9; p = 0,001). En comparación con los partos con fórceps, también se ha comprobado un mayor riesgo de traumatismo de los tejidos blandos (OR 2,1; p = 0,004), cefalohematoma (OR 2,2; p = 0,046) e ictericia (OR 1,4; p = 0,012) en los partos con ventosa. Los partos con ventosa presentaron mayor incidencia de complicaciones mayores que los restantes partos vaginales, pero la diferencia no fue significativa. Las 2 muertes ocurrieron en partos con ventosa (1,1 por 1.000).
Las tasas de complicaciones neonatales menores fueron más altas en el parto con ventosa. Aunque las complicaciones mayores y la muerte también fueron más frecuentes, fueron poco comunes y no mostraron diferencias significativas. El parto con ventosa es una técnica con indicación obstétrica, pero que debe alertar sobre la necesidad de vigilancia de posibles complicaciones neonatales.
The purpose of this study was to assess the neonatal morbidity and mortality associated with vacuum-assisted vaginal deliveries compared to all other vaginal deliveries, and to identify the associated risk factors.
We conducted a retrospective case-control study in a level iii maternity hospital between 2012 and 2016, including 1,802 vacuum-assisted vaginal deliveries and 2 control groups: 1802 spontaneous deliveries and 909 forceps-assisted deliveries. We considered minor complications (soft tissue trauma, cephalohaematoma, jaundice, intensive phototherapy, transient brachial plexus injury) and major complications (hypoxic-ischaemic encephalopathy, intracranial and subgaleal haemorrhage, seizures, cranial fracture, permanent brachial plexus injury), admission to the neonatal intensive care unit and death.
The risk of soft tissue trauma (aOR, 2.4; P<.001), cephalohaematoma (aOR, 5.5; P<.001), jaundice (aOR, 4.4; P<.001), intensive phototherapy (aOR, 2.1; P<.001) and transient brachial plexus injury (aOR; 2.1, P=.006) was higher in vacuum deliveries compared to spontaneous deliveries. Admission to the neonatal intensive care unit was also higher in vacuum deliveries compared to spontaneous deliveries (OR, 1.9; P=.001). When we compared vacuum with forceps deliveries, we found a higher risk of soft tissue trauma (OR, 2.1; P=.004), cephalohaematoma (OR, 2.2, P=.046) and jaundice (OR, 1.4; P=.012). Major complications were more frequent in the vacuum group comparing with the control groups, but the difference was not significant. The 2 deaths occurred in vacuum deliveries (1.1 per 1000).
The proportion of minor neonatal complications was higher in the vacuum-assisted delivery group. Although major complications and death were also more frequent, they were uncommon, with no significant differences compared to the other groups. There are obstetrical indications for vacuum delivery, but it should alert to the need to watch for potential neonatal complications.
Neonatal Nervous System Trauma
2017, Swaiman's Pediatric Neurology: Principles and Practice: Sixth Edition
Vaginal delivery under epidural analgesia in pregnant women with a diagnosis of moyamoya disease
2015, Journal of Stroke and Cerebrovascular Diseases
Moyamoya disease more commonly occurs in young people and women, so patients with this disease may experience pregnancy and delivery. Cesarean section (CS) is often chosen as the mode of delivery for these patients in Japan. No appropriate mode of delivery has yet been established for pregnant women with moyamoya disease in terms of stroke prevention. We have used vaginal delivery under epidural analgesia (EA) in such patients unless CS has been indicated for the maternal or fetal reasons. This study retrospectively analyzed our patients with moyamoya disease who gave birth to confirm the safety of vaginal delivery under EA.
Twelve consecutive patients diagnosed with moyamoya disease had 14 deliveries at our hospital between September 2004 and January 2013. The incidences of intrapartum stroke were compared between cases of vaginal delivery under EA and CS cases.
Ten vaginal deliveries under EA and 4 elective CSs were performed. No intrapartum stroke was observed during either vaginal delivery under EA or CS. Among the patients who underwent vaginal delivery under EA, 1 parturient who experienced 2 deliveries suffered transient ischemic attack during both postpartum periods. All 14 infants were healthy without sequelae.
Vaginal delivery under EA is an option for patients with moyamoya disease, provided that close cooperation with neurosurgeons, obstetricians, and anesthesiologists is assured.

View all citing articles on Scopus

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Head Trauma After Instrumental Births

Section snippets

Scalp bruises and lacerations

Summary

Best Pract Res Clin Obstet Gynaecol

Gynecol Obstet Fertil

Best Pract Res Clin Obstet Gynaecol

Obstet Gynecol

Eur J Obstet Gynecol Reprod Biol

Clin Perinatol

Am J Obstet Gynecol

Pediatr Neurol

Medical Hypotheses

J Biomech

Semin Perinatol

Lancet

Pediatr Neurol

Pediatr Neurol

Am J Obstet Gynecol

Int J Gynaecol Obstet

Int J Gynaecol Obstet

Lancet

Am J Obstet Gynecol

Eur J Obstet Gynecol Reprod Biol

Society of Obstetricians and Gynaecologists of Canada. Guidelines for operative vaginal birth. SOGC. Number 148, May 2004

Int J Gynaecol Obstet

Operative vaginal delivery. Guideline No. 26. Clinical green top guidelines

U.S. trends in obstetric procedures, 1990–2000

Birth

American College of Obstetrics and Gynecology. Operative vaginal delivery. Clinical management guidelines for obstetrician-gynecologists. American College of Obstetrics and Gynecology

Int J Gynaecol Obstet

Forceps delivery in modern obstetric practice

BMJ

Vacuum-assisted delivery: a review

J Matern Fetal Neonatal Med

Vacuum extraction versus forceps for assisted vaginal delivery

Cochrane Database Syst Rev

Alopecia associated with birth injury

Obstet Gynecol

A randomised controlled trial of a new handheld vacuum extraction device

BJOG

Birth trauma in the head and neck

Arch Otolaryngol Head Neck Surg

Operative vaginal delivery: a cause of birth injury or is it?

Clin Obstet Gynecol

Head injuries after instrumental vaginal deliveries

Curr Opin Obstet Gynecol

Neonatal complications of vacuum-assisted delivery

Obstet Gynecol

Soft versus rigid vacuum extractor cups for assisted vaginal delivery

Cochrane Database Syst Rev

Cephalhematomas revisited. When should a diagnostic tap be performed?

Clin Pediatr (Phila)

Neonatal subgaleal hemorrhage and its relationship to delivery by vacuum extraction

Obstet Gynecol Surv