General Obstetrics and Gynecology: Obstetrics
Comparison of “instrument-associated” and “spontaneous” obstetric depressed skull fractures in a cohort of 68 neonates

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Objective

A depressed skull fracture is an inward buckling of the calvarial bones and is referred to as a “ping-pong” fracture. This study aimed to look at differences between “spontaneous” and “instrument-associated” depressed skull fractures.

Study design

This retrospective, case-control analysis included every neonate who was admitted with a depressed skull fracture between 1990 and 2000. Cases after a spontaneous vaginal delivery, elective cesarean delivery, or cesarean delivery that was performed during labor without previous instrument use were classified as “spontaneous”(n = 18 cases). Cases after a delivery in which forceps or a vacuum cup had been used either successfully or unsuccessfully were classified as “instrument-associated” (n = 50 cases). Continuous data were analyzed with 2-tailed unpaired t tests; χ2 analysis was used for nominal data. A probability value of <.05 was considered statistically significant.

Results

Fifty depressed skull fractures were associated with an instrument delivery, and 18 depressed skull fractures were classified as “spontaneous.” The only obstetric parameter that differed significantly between the 2 groups was the length of the active phase. Among the 68 neonates, 15 neonates underwent prolonged second stage, forceps or manual head rotation, or forceps use during elective cesarean delivery. All “instrument-associated” cases were caused by forceps application or sequential instrument use; depressed skull fractures never occurred after isolated vacuum extraction. Every type of forceps was involved. Intracranial lesions were significantly more frequent in the instrument-associated group (30% vs 0%; P = .02). Two infants sustained persistent severe motor disabilities.

Conclusion

Depressed skull fractures occur in the setting of spontaneous and operative deliveries, although the incidence is higher in the latter case. Depressed skull fractures that are associated with instrumental deliveries are significantly more likely to be associated with intracranial lesions. Persistent disabilities are rare.

Section snippets

Material and methods

We performed a retrospective, case-control analysis. Because of the study design, the study protocol has received exemption from the Institutional Review Board. This study was conducted in 2 neurosurgery units that are located at Necker and Pierre Wertheimer hospitals. These hospitals are located in Paris and Lyon, France's 2 largest cities, and serve as a catchement area of 11 million people. This study included all neonates who were admitted to 1 of these neurosurgery wards with a DSF between

Results

During the study period, 75 neonates with a DSF were admitted to the neurosurgical units. Births took place in 38 maternity hospitals. Seven cases were excluded (6 files were incomplete, and 1 case was associated with a large [antenatal] porencephalic cyst), which left 68 cases for analysis. The neurosurgical hospitals in Paris and Lyon are referral centers for 183 maternity hospitals. These maternity hospitals delivered 1,994,250 babies between 1990 and 2000.7 Therefore, the incidence of

Comment

The 2 neurosurgery units that were involved in this study act as neurosurgical neonatal referral centers for the 2 largest cities in France. Therefore, it is very unlikely that cases were missed. Moreover, DSF are of the “ping-pong” type and are diagnosed easily clinically, which means that DSF are very unlikely to remain undiagnosed.8 Theoretically, files for neonates who died in the obstetrics ward after an instrumental delivery could have been missed. However, a survey of 2577 forceps

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