An infant is delivered with the use of forceps. what should the nurse assess for in the newborn?

An ‘intervention’ is an action taken by a midwife or doctor that literally means that they intervene in the birthing process to assist in the delivery of your baby.

There are several ways an intervention can occur. The most common are assisted delivery by forceps or a vacuum (ventouse) cup, an episiotomy or an induced labour.

Whatever the method used, an intervention occurs when it becomes clear that you will be unable to give birth without some kind of assistance or your baby is in distress and needs to be born more quickly.

Your baby's heart rate will be monitored throughout your labour to watch for any signs that the baby is in distress and that something needs to be done.

You should discuss all of these methods with your midwife or doctor during your pregnancy so you understand why they might be considered.

If you’re healthy and your pregnancy and labour are normal, you probably won't need any intervention.

Assisted delivery

An assisted delivery, sometimes called an 'instrumental delivery', is when your doctor will help in the birthing process by using instruments such as a ventouse (vacuum extractor) or forceps to help you deliver your baby.

Both ventouse and forceps are safe and only used when necessary for you and your baby. 

Read more about assisted delivery.

Episiotomy

An episiotomy is a procedure performed during labour where a small cut is made to widen your vagina to assist with the delivery of your baby.

An episiotomy may be recommended if your baby develops a condition known as 'fetal distress' where the baby's heart rate significantly increases or decreases before birth.

Another reason for carrying out an episiotomy is when it is necessary to widen your vagina so that instruments, such as forceps or a ventouse, can be used to assist with the birth.

Read more about episiotomy.

Induced labour

Sometimes, your doctor may recommend inducing labour – bringing it on artificially instead of waiting for it to begin. The reasons for inducing a baby may include a multiple birth, diabetes, kidney problems, high blood pressure or when a pregnancy is past 41 weeks.

If your labour is being induced it is important that you discuss this procedure with your doctor or midwife. The benefit of being induced must outweigh the risks. An induction of labour has some risks, for example there is a higher risk of forceps or vacuum delivery and caesarean section operation.

Read more about induced labour.

A cephalohematoma is an accumulation of blood under the scalp. During the birth process, small blood vessels on the head of the fetus are broken as a result of minor trauma. Specific to a cephalohematoma, small blood vessels crossing the periosteum are ruptured and serosanguineous or bloody fluid collects between the skull and the periosteum. Because the collection of blood is sitting on top of the skull and not under it, there is no pressure placed on the brain. This activity reviews the workup of cephalohematomas and describes the role of health professionals working together to managing this condition.

Objectives:

• Review the cause of cephalohematoma.

• Describe the presentation of a patient with cephalohematoma.

• Summarize the treatment of cephalohematoma.

• Outline the workup of cephalohematomas and describe the role of health professionals working together to manage this condition.

A cephalohematoma is an accumulation of blood under the scalp. During the birth process, small blood vessels on the head of the fetus are broken as a result of minor trauma. Specific to a cephalohematoma, small blood vessels crossing the periosteum are ruptured, and serosanguineous or bloody fluid collects between the skull and the periosteum. The periosteum is the membrane that covers the outer surface of all bones. The bleeding is gradual; therefore, a cephalohematoma is not evident at birth. [1][2][3] A cephalohematoma develops during the hours or days following birth. Because the fluid collection is between the periosteum and the skull, the boundaries of a cephalohematoma are defined by the underlying bone. In other words, a cephalohematoma is confined to the area on top of one of the cranial bones and does not cross the midline or the suture lines. Because the collection of blood is sitting on top of the skull and not under it, there is no pressure placed on the brain.

The cause of a cephalohematoma is rupture of blood vessels crossing the periosteum due to the pressure on the fetal head during birth. During the process of birth, pressure on the skull or the use of forceps or a vacuum extractor rupture these capillaries resulting in a collection of serosanguineous or bloody fluid.[4] Factors that increase pressure on the fetal head and the risk of the neonate developing a cephalhematoma include:

• Long labor

• Prolonged second stage of labor

• Macrosomia

• Weak or ineffective uterine contractions

• Abnormal fetal presentation

• Instrument-assisted delivery with forceps or vacuum extractor

• Multiple gestations

These factors contribute to the traumatic impact of the birthing process on the fetal head.

Cephalohematoma is a subperiosteal accumulation of blood that occurs with an incidence of 0.4% to 2.5% of all live births. They are more common in primigravidae, large infants, infants in an occipital posterior or transverse occipital position at the start of labor, and following instrument-assisted deliveries with forceps or a vacuum extractor. For unknown reasons, cephalohematomas occur more often in male than in female infants.[5]

Cephalohematoma is a minor condition that occurs during the birth process. Pressure on the fetal head ruptures small blood vessels when the head is compressed against the maternal pelvis during labor or pressure from forceps or a vacuum extractor used to assist the birth. Shearing action between the periosteum and the bone causes bleeding of the emissary and diploic veins. As blood accumulates, the periosteum lifts away from the skull. As the bleeding continues and fills the subperiosteal space, pressure builds, and the accumulated blood acts as a tamponade to stop further bleeding.

A comprehensive history of labor and birth is needed to identify newborns at risk of developing a cephalohematoma. Factors that increase pressure on the fetal head and the risk of developing a cephalhematoma include:

• Long labor

• Prolonged second stage of labor

• Macrosomia

• Weak or ineffective uterine contractions

• Abnormal fetal presentation

• Instrument-assisted delivery with forceps or vacuum extractor

• Multiple gestations

Because of the slow nature of subperiosteal bleeding, cephalohematomas usually are not present at birth but develop hours or even days after birth. Therefore, repeated inspection and palpation of the newborn’s head is necessary to identify the presence of a cephalohematoma. Ongoing assessment to document the appearance of a cephalohematoma is important. Once a cephalohematoma is present, assessing and documenting changes in size is continued. The most obvious sign of a cephalohematoma is a soft, raised area on the newborn’s head. A firm, enlarged unilateral or bilateral bulge on top of one or more bones below the scalp characterizes a cephalohematoma. The raised area cannot be transilluminated, and the overlying skin is usually not discolored or injured. Cranial sutures define the boundaries of the cephalohematoma. The parietal bones are the most common site of injury, but a cephalohematoma can occur over any of the cranial bones.

There is no diagnostic test for a cephalohematoma. Diagnosis is based on the characteristic bulge on the newborns head. However, some providers may request additional tests, including x-rays, CT scan, or ultrasound to evaluate for potential fractures of the skull or other problems below the skull, which could impact the newborn’s brain. Additional testing is especially warranted if the newborn's behavior changes or other problems, such as respiratory, cardiovascular, or neurological are present.

Treatment and management of a cephalohematoma are primarily observational. The mass from a cephalohematoma takes weeks to resolve as the clotted blood is slowly absorbed. Over time, the bulge may feel harder as the collected blood calcifies. The blood then starts to be reabsorbed. Sometimes the center of the bulge begins to disappear before the edges do, giving a crater-like appearance. This is the expected course for the cephalohematoma during resolution.[6][7][8][9]

One should not attempt to aspirate or drain the cephalohematoma. Aspiration is not effective because the blood has clotted. Also, entering the cephalohematoma with a needle increases the risk of infection and abscess formation. The best treatment is to leave the area alone and give the body time to reabsorb the collected fluid.

Usually, cephalohematomas do not present any problem to a newborn. The exception is an increased risk of neonatal jaundice in the first days after birth. Therefore, the newborn needs to be carefully assessed for a yellowish discoloration of the skin, sclera, or mucous membranes. Noninvasive measurements with a transcutaneous bilirubin meter can be used to screen the infant. A serum bilirubin level should be obtained if the newborn exhibits signs of jaundice.

Rarely, large calcified cephalhematomas need surgical treatment.[10][11]

Differential Diagnosis

• Intraventricular haemorrhage

Newborns with a cephalohematoma and no other problems are usually sent home with their parent or parents. Parents need to observe the bulge on the newborn's head for any changes, including an increase in size during the first week following birth. Parents also need to monitor for any behavioral changes such as increased sleepiness, increased crying, change in the type of cry, refusal to eat, and other signs that the infant might be in pain or having a problem. Recovery from a cephalohematoma requires little action except for ongoing observation. While seeing a bulge on a newborns head can be concerning, a cephalohematoma is rarely dangerous and resolves with no lasting consequences.

Cephalohematoma is a clinical diagnosis and is usually a benign complication of delivery. However, prior to discharge the nurse, obstetrician and the delivery nurse should educate the patient on the importance of monitoring the infant for the first week. The infant should be observed for any behavior change, feeding difficulties, emesis and failure to thrive. The majority of infants have an uneventful recovery.[12] an interprofessional team approach will provide the best patient education and good outcomes. [Level V]

Review Questions

Illustration. Cephalohematoma, subgaleal hemorrhage, caput succedaneum. Scalp, skull, periostium, dura mater, edema, sagittal suture, edema. Contributed by Chelsea Rowe

1.

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