Patient Presentation
A 2-week-old female came to clinic for her 2 week well child appointment. Her parents felt that she was doing well with feeding every 2-3 hours with many urine and stool diapers per day. Her mild jaundice had disappeared. They were concerned about some hard masses on her right cheek. They had noticed the masses about 1 week prior and they did not seem to bother the baby.
The past medical history showed a term female who was large for gestational age born to a first time mother. There were no problems with the pregnancy, but there had been a prolonged second stage and the fetus had started to have an abnormal heart rate. She was delivered by forceps and the only abnormality after delivery was some bruising on her right cheek which resolved in a couple of days.
The pertinent physical exam revealed a vigorous infant with a weight 4.155 kg (Birth weight = 4.134 kg, >90%), length 53 cm (~90%) and head circumference of 35.5 cm (~90%). She was not jaundiced. HEENT showed two slightly irregular, harder masses just anterior to the temporomandibular joint in the right cheek that were ~5-7 mm in size and were mobile. They appeared to be in the subcutaneous tissue and not in the muscle and did not cause any pain or irritation of the infant when examined. She had no other masses noted. Oral and ear examinations were normal. The rest of her examination was normal.
The diagnosis of a healthy, large for gestational infant with small cheek masses was made. The pediatrician thought that given the history, location and texture of the masses, that this was most likely fat necrosis secondary to the forceps delivery. Other considerations included hematoma or congenital malformation or deformation. The radiologic evaluation confirmed that these were subcutaneous fat necrosis. The patient was monitored for hypercalcemia as a consequence of the fat necrosis and all testing was normal. The masses resolved by 2 months of life.
Discussion
The main outcome of any delivery is to have a healthy mother and healthy child. For millinea, mothers delivered babies with the help of their mothers and learned women without the benefits of potential instrumented interventions when complications arose, and today they are options for some deliveries. Instrumented delivery techniques have markedly decreased maternal and neonatal morbidity and mortality. Instrument delivery techniques in the second stage of labor includes forceps (begun in the 1600s), vacuum delivery (mainly use began in 1950s) and second stage cesarean section (cesarean section being first used to surgically remove a live fetus from a dead or dying mother). As with any procedure there are potential benefits and complications. Benefits include assisting in safe delivery, decreasing the amount of time for delivery and thereby other potential complications. Measures that help birthing without instrumentation includes continuous maternal support, upright or tilted maternal positioning, mobility during labor, and decreased use of epidural anesthesia. These cannot always be used or other issues arise during the birthing process that make an instrumented delivery a consideration.
Subcutaneous fat necrosis in neonates is a transient hypodermatitis. It can occur within a few days and resolves over a few weeks with good prognosis although trophy, ulceration or scarring can occur. It is usually seen on the back, buttocks, thighs, cheeks, and shoulder. It is possibly caused by mechanical pressure and local hypoxia to the tissues and forms nodules.
Learning Point
Potential complications of forceps or vacuum delivery include:
- Maternal
- Perineal or vaginal tear
- Pelvic floor damage
- Genital prolapse
- Urinary incontinence
- Fecal incontinence
- Post partum hemorrhage
- Failure of procedure and need for subsequent procedure
- Infant
- Facial nerve palsy
- Bruising of skin or other injury of soft tissues such as fat or muscle
- Scalp or skin laceration
- Corneal injury
- Retinal hemorrhage (no long-term effects)
- Bleeding
- Caput succadaneum – hematoma or fluid under the scalp skin
- Cephalohematoma – subperiosteal hematoma of the scalp, does not cross suture lines
- Subgaleal hematoma
- Subdural hematoma
- Skull fracture
- Cervical spine injury
- Hypoxia
- Hyperbilirubinemia
Locations of various potential locations for blood and/or fluid accumulations in the neonatal head include (from external to internal):
- Skin
- Caput succadaneum – can cross suture lines, caused by pressure on the infant’s head from the uterus or vaginal wall which causes fluid accumulation
- Epicranial aponeurosis
- Subgaleal hematoma – can cross suture lines, caused by rupture of emissary vein in the loose aponeurotic tissue.
Can be very large as the epicranial aponeurosis roughly encases the upper part of the head. A subgaleal hematoma can extend from the eyes to the nape of the neck. A potential large fluid accumulation can mean possible hypovolemia. - Periosteum of bone (external)
- Cephalohematoma – does not cross suture lines, caused by periosteal bleeding
- Skull
- Periosteum of bone (internal)
- Epidural hematoma – caused by rupture of the middle meningeal artery with blood accumulation, often occurs with a skull fracture
- Dura mater
- Subdural hematoma – caused by rupture of bridging veins
- Brain
Figure 134 – Neonatal Head Fluid Accumulation Locations from AMH Sheikh, 2006, https://commons.wikimedia.org/wiki/File:Scalp_hematomas.jpg
Questions for Further Discussion
1. What are potential complications for large for gestational infants? A review can be found here
2. What are potential causes for small for gestational infants? A review can be found here
3. How common are cesarean deliveries in your location?
Related Cases
- Disease: Subcutaneous Fat Necrosis | Childbirth
- Symptom/Presentation: Mass or Swelling
- Age: Newborn
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Childbirth and Childbirth Problems.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Norton KI, Som PM, Shugar JMA, Rothchild MA, Popper L. Subcutaneous Fat Necrosis of the Newborn: CT Findings of Head and Neck Involvement. AJNR. 1997;18:547-550.
Mahe E, Girszyn N, Hadj-Rabia S, Bodemer C, Hamel-Teillac D, De Prost Y. Subcutaneous fat necrosis of the newborn: a systematic evaluation of risk factors, clinical manifestations, complications and outcome of 16 children. Br J Dermatol. 2007;156(4):709-715. doi:10.1111/j.1365-2133.2007.07782.x
Keriakos R, Sugumar S, Hilal N. Instrumental vaginal delivery — back to basics. J Obstet Gynaecol J Inst Obstet Gynaecol. 2013;33(8):781-786. doi:10.3109/01443615.2013.813917
Seki H. Complications with vacuum delivery from a forceps-delivery perspective: Progress toward safe vacuum delivery. J Obstet Gynaecol Res. 2018;44(8):1347-1354. doi:10.1111/jog.13685
Giacchino T, Karkia R, Ahmed H, Akolekar R. Maternal and neonatal complications following Kielland’s rotational forceps delivery: A systematic review and meta-analysis. BJOG Int J Obstet Gynaecol. 2023;130(8):856-864. doi:10.1111/1471-0528.17402
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa
Pediatric Education 
