Severe intrauterine bacterial sepsis may present with shock in the delivery room or immediately after the infant is transferred to the nursery. Typically these infants are mottled, hypotonic, and cyanotic and have diminished peripheral pulses. They have a normal hemoglobin concentration but may manifest neutropenia, thrombocytopenia, and disseminated intravascular coagulation. Peripheral symmetrical gangrene (purpuric rash) often is a sign of hypotensive shock in infants with severe congenital bacterial infections. Congenital left ventricular cardiac obstruction (critical aortic steno-sis or hypoplastic left heart syndrome) also produces shock, although not usually in the delivery room.
Treatment of newborn infants with shock should involve the management approaches used for the sick infant. Problems may be anticipated through knowledge of the infant’s immune status, evidence of hydrops, or suspicion of intrauterine infection or anomalies. Stabilization of the airway and institution of respiratory support are essential. Hypovolemic shock should be managed with repeated boluses of 10 to 15 mL/kg of normal saline or lactated Ringer solution. If severe immune hemolysis is predicted, blood typed against the mother’s blood should be available in the delivery room and should be given to the newborn if signs of anemia and shock are present. Thereafter, all blood should be crossmatched with the infant’s and mother’s blood before transfusion. Drugs such as dopamine, epinephrine, or cortisol may improve cardiac output and tissue perfusion.
Birth injury refers to avoidable and unavoidable injury to the fetus during the birth process. Caput succedaneum is a diffuse, edematous, often dark swelling of the soft tissue of the scalp that extends across the midline and suture lines. In infants delivered from a face presentation, soft tissue edema of the eyelids and face is an equivalent phenomenon. Caput succedaneum may be seen after prolonged labor in full-term and preterm infants. Molding of the head often is associated with caput succedaneum and is the result of pressure that is induced from overriding the parietal and frontal bones against their respective sutures.
A cephalhematoma is a subperiosteal hemorrhage that does not cross the suture lines surrounding the respective bones. A linear skull fracture rarely may be seen underlying a cephalhematoma. With time, the cephalhematoma may organize, calcify, and form a central depression.
Infants with cephalhematoma and caput succedaneum require no specific treatment. Occasionally a premature infant may develop a massive scalp hemorrhage. This subgaleal bleeding and the bleeding noted from a cephalhematoma may cause indirect hyperbilirubinemia requiring phototherapy. Retinal and subconjunctival hemorrhages are common but usually are small and insignificant. No treatment is necessary.
Spinal cord or spine injuries may occur in the fetus as a result of the hyperextended star gazing posture. Injuries also may occur in infants after excessive rotational (at C3–4) or longitudinal (at C7–T1) force is transmitted to the neck during vertex or breech delivery. Fractures of vertebrae are rare; trauma may cause direct damage to the spinal cord, leading to transection and permanent sequelae, hemorrhage, edema, and neurologic signs. Rarely, a snapping sound indicating cord transection rather than vertebral displacement is heard at the time of delivery. Neurologic dysfunction usually involves complete flaccid paralysis, absence of deep tendon reflexes, and absence of responses to painful stimuli below the lesion. Painful stimuli may elicit reflex flexion of the legs. Infants with spinal cord injury often are flaccid, apneic, and asphyxiated, all of which may mask the underlying spinal cord transection.