Birth injury after cesarean section at 24 weeks of gestation: a large scalp laceration

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Cesarean section (CS), compared with vaginal delivery, has a lower incidence of neonatal birth injury. Previously, we reported a femur fracture after term CS in this journal [1]. In a pregnant woman with chronic abruption oligohydramnios sequence, CS was performed at 24 weeks under general anesthesia due to continued oligohydramnios and elevated C-reactive protein level (4.5 mg/dL). The obstetrician had 20 years of experience. Being in head presentation, lower segment transverse incision was made with surgical knife: the incision was stopped before entering the uterine cavity to avoid direct injury to the fetal scalp. The uterine cavity was entered with a finger and the incision was extended laterally by both index fingers (Fig. 1a). Then the doctor recognized something ‘‘white’’ just beneath the fingers. In retrospect, it was the skull bone: the scalp skin may have been lacerated by the fingers, sliding off from the underlying skull bone (Fig. 1b). This was well reconstructed. Bleeding from the laceration was slight, requiring no blood transfusion. Extra-or-subdural hematoma or intra-ventricular hemorrhage was absent. The infant, weighing 544 g with Apgar score 4/7 (1/5 min), died the next day due to prematurity. Autopsy was not performed. The scalp laceration itself was not considered to have influenced the outcome. Another similar experience: a scalp laceration in an infant after 23 weeks’ CS. Oligohydramnios due to premature rupture of the membranes and signs of intrauterine infection required CS. The fetal head was deeply engaged and thus the hand was put deeply into the uterine cavity, pulling out the fetal head with the fingers. In retrospect, the scalp, being pushed and possibly scratched by the fingers, was lacerated at the parietal area. The infant died next day due to prematurity. The laceration was not considered to have influenced the outcome. There is a close similarity between the two patients: preterm CS, oligohydramnios, and intrauterine infections. A previous report [2] also showed that ruptured membranes and thus oligohydramnios were the risk factors of fetal scalp laceration, in which, however, infants suffering laceration were almost term infants (average of 38.67 weeks), with the earliest and the lightest being 29 weeks and 825 g of birth weight, respectively. Its context was that obstetricians should avoid direct injury to the fetal scalp with the knife or scalpel [2]. The present significance is different: pushing or scratching the scalp skin with fingers was the considered culprit. Skin and the underlying skull bone, especially at the parietal area, are more loosely connected than skin and other body parts such as the extremities or the trunk. This is more exaggerated in preterm infants. Intra-uterine infection, weakening the skin, may also have caused scalp laceration. Oligohydramnios, pushing the fetal head tightly to the uterine wall, obliged the obstetrician to put fingers into the narrow space between the fetal head and the uterine wall, which may also have caused this injury. The CS procedure was performed gently, considering the infant’s prematurity; however, a much gentler maneuver S. Matsubara (&) R. Usui Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan e-mail: matsushi@jichi.ac.jp