Definition

• Accumulation of blood in the loose connective tissue of subgaleal space 
• Damaged emissary veins connecting subgaleal space to the intracranial venous sinuses can lead to significant blood loss
  • up to two-thirds of circulating volume with significant morbidity and mortality (≥50% in severely affected cases)

Risk factors

Vacuum extraction

• Incorrect positioning of cup 
  • cup marks on sagittal suture
  • leading edge of cup <3 cm from anterior fontanelle
• Prolonged extraction time (>20 min)
• >3 pulls or >2 cup detachments
• Failed vacuum extraction

Maternal factors

• Primiparous
• PROM >12 hr
• Maternal exhaustion
• Prolonged second stage
• High or mid cavity forceps delivery

Neonatal factors

• Macrosomia 
• Coagulopathy (vitamin K deficiency, Factor VIII or Factor IX deficiency) 
• Low-birth-weight
• Male sex 
• Low Apgar scores 
• Resuscitation at birth
• Cord blood acidosis
• Fetal malpresentation 
• Can occur in unassisted deliveries

Symptoms and signs

• Local signs 
  • generalised swelling or boggy consistency of scalp
    • not limited by sutures
    • especially at the cup site 
    • fluctuant leather-like pouch filled with fluid 
  • elevation and displacement of ear lobes and periorbital oedema
  • irritability and pain on handling
• Systemic signs 
  • hypovolemic shock
    • tachycardia
    • tachypnoea
    • dropping haematocrit
    • increasing lactate or worsening acidosis
    • poor activity
    • pallor
    • hypotension
    • acidosis
  • neurological dysfunction and seizures (late sign)
  • ischaemic end organ damage to liver or kidneys 
    • can manifest as worsening liver and renal function
    • poor prognostic indicator

Investigations

• FBC and coagulation on admission
  • repeat at clinical team’s discretion
• Group and blood crossmatch (notify blood bank). See Massive haemorrhage guideline)
• Venous/capillary gas including lactate and base excess, electrolytes (2–4 hrly) 
• Blood glucose 

• Cephalohematoma: subperiostial bleeding limited by suture lines
• SGH: crosses suture lines 
• Caput succedaneum: oedematous collection of serosanguinous fluid in the subcutaneous layer of the scalp
  • has distinct borders
  • does not enlarge
  • not fluctuant 
• Chignon: artificial caput succedaneum limited to suction cap application site

Initial management

• Follow local guidelines for monitoring of newborns following vaginal operative delivery 
• Alert paediatric team
• Urgent review by middle grade/consultant
• If SGH confirmed, admit to NNU immediately
  • inform consultant (if not involved in assessment)
• Apply pressure bandage to head
• Peripheral IV access
  • leave indwelling for 12 hr
• Continuously monitor:
  • heart rate
  • respiration
  • oxygen saturation
  • blood pressure (non-invasively if no arterial line) ≥24 hr
• Continue to assess capillary refill and peripheral perfusion
• Regularly observe and palpate scalp swelling to assess for:
  • continuing blood loss
  • change in head shape or circumference 
    • measure head circumference hourly for the first 6–8 hr after birth
    • take several measurements each time and record the highest 
    • 1 cm increase in circumference = 40 mL blood loss
    • if pressure bandage in place measure over the bandage
    • interpret head circumference changes in conjunction with all other clinical parameters and not in isolation 
  • change in colour
  • displacement of ears
• Volume replacement: 
  • inform consultant 
  • see Massive haemorrhage guideline, and Recognition of hypovolaemia below 
  • Group O RhD negative blood is immediately available on labour suite/obstetric theatres
• Monitor urine output
• Maintain blood glucose >2.6 mmol
• Repeat FBC and coagulation studies (4–6 hr after initial assessment)
• Inotropes, vasopressors, multiple packed red cell transfusions and clotting products may be required for severe cases of shock [using packs 1 and 2 (see Massive haemorrhageguideline)]
• Ongoing assessment for jaundice 

• High/increasing heart rate (>160 bpm)
• Low/falling Hb or haematocrit
• Poor peripheral perfusion with slow central capillary refill (>3 sec)
• Low/falling blood pressure (mean arterial blood pressure <40 mmHg in term baby)
• Presence of, or worsening of, metabolic acidosis
• If available use echocardiography to assess volume status
  • small systemic veins and low ventricular filling volumes can indicate hypovolaemia
• If any of above present, or concern of ongoing haemorrhage from scalp assessment/neurological dysfunction/evidence of renal or hepatic impairment - follow Massive haemorrhage guideline

• Hypoxic ischaemic encephalopathy [see Hypoxic ischaemic encephalopathy (HIE) guideline]
• Brain trauma resulting in cerebral oedema and/or intracranial haemorrhage 
• Subdural haematoma
• Dural tear with herniation
• Superior sagittal sinus rupture
• Pseudomeningocele and encephalocele
• Subconjunctival and retinal haemorrhage
• Elevated intracranial pressure from SGH mass effect 
• Skull fractures 

• If any of the intracranial concomitant injuries above suspected, neuroimaging to be undertaken once baby stabilised following discussion with radiologist to establish best modality
• Monitor on NNU for ≥24 hr
• Discuss with neurosurgical team