A Heads Up on Subgaleal

HemorrhageCheryl McDuffie MSN, FNP-C, RNC-NIC

Disclosures• I have nothing to disclose

Objectives• After this presentation the learners will be

able to:o Differentiate between common scalp swellings and

subgaleal hemorrhageo Identify delivery history and physical assessment findings

which warrant frequent reassessment for signs of subgaleal hemorrhage

The Case• This is a published case presentation.• Any resemblance to a case in any local

hospital is purely coincidental.• All pictures are publicly available on the

internet. All patient pictures are from published articles in reference list.

Case of Baby JaneAssessment• 41 week, 3891Gm female• Gravida-1 Para-0• Spontaneous labor• Vacuum extraction vaginal delivery • Tight nuchal cord cut approximately 50

seconds prior to delivery• Mild shoulder dystocia• Apgars 3 @ 1, 4 @ 5, and 7 @ 10 minutes

Scalp

http://www.studyblue.com/notes/note/n/exam‐3/deck/6048127

Scalp swellings 

Scalp swellings• Caput succedaneum

o Serosanguineous fluid in subcutaneous tissues of presenting part

o Soft spongy, crosses suture lines, shifts with positioning

o Minimal blood losso Resolves in 48-72 hours

Caput succedaneum

Scalp swellings• Cephalohematoma

o Blood accumulation between skull bone and periosteum

o Does not cross suture lines, initially firmo Location- parietal and occipital bones,

85% unilateralo Blood loss is rarely severeo Resolves in 2 weeks to 3 months

Cephalohematoma

http://newborns.stanford.edu/PhotoGallery/Cephalohematoma1.html

Scalp swellings• Subgaleal hemorrhage

o Rupture of the emissary veins, blood accumulation in the subaponeurotic space.

o Massive blood loss possible, no barrier to stop the bleeding.o Space can hold 240ml

• Newborn blood volume 78-86ml/Kg (Harriet Lane, 2012)• 3Kg infant, 80ml/Kg = 240ml

o Space extends from nape of neck to orbits of the eyes and from ear to ear.

o May see fluid waveo Displace ear anteriorlyo Swelling around the eyeso Resolves in 2-3 weeks High morbidity

http://www.oganatomy.org/projanat/neuroanat/3/eight.htm

http://www.studyblue.com/notes/note/n/11‐27‐12‐3pm‐scalp‐‐cranial‐cavity/deck/4588068

Subgaleal hemorrhage

http://newborns.stanford.edu/PhotoGallery/Subgaleal3.html

http://www.ped.si.mahidol.ac.th/e‐diary/makehtml/division/thrathip/birthinjury/birth1.html

How I  think about things…..

Caput 

CephalohematomaSubgaleal hemorrhage

Incidence • 1 in 2500 spontaneous vaginal births• 10 fold increase with the use of forceps or vacuum• Vacuum use is reported in approximately 49% of all

subgaleal hemorrhage (Schierholz, E., Walker, S.R., 2010)

Vacuum Assisted Delivery

http://www.aafp.org/afp/2008/1015/p953.html

http://www.kentecmedical.com/manufacturer_detail.phtml?mfg_id=140&pline_id=155&src=cat

http://www.utahmed.com/vacuumdelivery.htm

http://news.thomasnet.com/fullstory/Vacuum‐Assisted‐Delivery‐System‐is‐secure‐and‐gentle‐20004131

http://en.wikipedia.org/wiki/Ventouse

http://ispub.com/IJPN/5/2/7678

Risk factors associated with SGH after vacuum‐ assisted delivery

• Nulliparous mother• Failed vacuum extraction• Inadvertent cup release (pop-offs)• Sequential use of vacuum and forceps• Apgar less than 8 @ 5 min following vacuum

assisted delivery• Deflexing cup application (cup edge less than

3 cm from anterior fontanel)• Paramedian cup application (cup centered

more than 1 cm lateral to sagittal suture)(Karlsen, 2013)

http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/dec16_6(suppl1)/Pages/07.aspx

What do we place on all newborns?

Case of Baby JaneAssessment• 41 week, 3891Gm female• Gravida-1 Para-0• Spontaneous labor• Vacuum extraction vaginal delivery • Tight nuchal cord cut approximately 50

seconds prior to delivery• Mild shoulder distocia• Apgars 3 @ 1, 4 @ 5, and 7 @ 10 minutes

What else would you like to know?

• Question 1• Question 2• Question 3

How long?• How long was the vacuum in place prior to

delivery?o Time from initiation of vacuum to delivery 21

minutes

How many?• How many pop-offs?

o “multiple pop-offs”

Where was the cup placed?

• Where is the chignon (cup mark)?o Unknown

Case of Baby JaneAssessment• 41 week, 3891Gm female• Gravida-1 Para-0• Spontaneous labor• Vacuum extraction vaginal delivery • Tight nuchal cord cut approximately 50

seconds prior to delivery• Mild shoulder distocia• Apgars 3 @ 1, 4 @ 5, and 7 @ 10 minutes

Case of Baby Jane• Baby required bag mask ventilation for ~ 4 minutes• On examination “bogginess” of scalp noted• Baby described as flaccid and “shocked” looking• To nursery for observation• 1.5 hrs of life transport called because baby paler

and unresponsive

Case of Baby Jane• Fluid boluses suggested but no IV access• Transport noted severe swelling of the baby’s scalp• Hct @ 3.5 hrs of life 34 compared to cord Hct 49• Rec’d 50ml/Kg crystalloid and blood plus glucose,

NaHCO3, Dopamine

Case of Baby Jane• Despite NICU care baby continued to deteriorate

with severe encephalopathy, profound hypotension, renal failure, disseminated intravascular coagulation (DIC), she died at 18 hours of life.

• Postmortem exam confirmed massive subgaleal hemorrhage, with several diastatic fractures and anoxic- ischemic changes within the brain.

Assessment• Get complete delivery history• Number of pop-offs, length of time with suction• Assess location of suction mark• Initial Head circumference• Reassessment of FOC- each cm increase in FOC =

approximately 40ml of blood loss (Reid, 2007)• Assess for signs of shock- increased HR, decreased

BP, increased cap refill, pallor

Plan• Diagnostic testing• Blood gas, Hct, clotting studies, • Blood products- Hypovolemic shock• Blood volume replacement (FFP, PRBC)• Platelets and clotting factors (DIC)• Inotropes to maintain adequate blood pressure

ImplementationNursing care

• Assess and stabilize respiratory status• Assess head and skull for abrasions, ecchymosis,

and swelling• Measure head circumference• Obtain laboratory studies: blood gas, type and

cross, CBC, coagulation studies• Obtain IV access; peripheral vs umbilical• Communicate with family, transport team, and

physicians

Evaluation• Continued frequent assessment of vital signs,

respiratory status, head examination and laboratory studies

Did I meet the objectives?• After this presentation the learners will be

able to:o Differentiate between common scalp

swellings and subgaleal hemorrhageo Identify delivery history and physical

assessment findings which warrant frequent reassessment for signs of subgaleal hemorrhage

References• Chang, H., Peng, C., Kao, H., Hsu, C., Hung, H., Chang, J. Neonatal subgaleal hemorrhage: Clinical

presentation, treatment, and predictors of poor prognosis. Pediatrics International. 49. 903-907.• Davis, D. J. (2001) Neonatal subgaleal hemorrhage: diagnosis and management. Canadian Medical

Association Journal. 164(10). 1452-1453.• Federal Drug Administration (1998) FDA public health advisory: Need for caution when using vacuum

assisted delivery devices. Retrieved on July 8, 2013 from http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/ucm062295.htm.

• Karlsen, K, (2013) The STABLE Program Learner Manual. S.T.A.B.L.E Inc. Salt Lake City, UT.• O’Grady, J.P. (2012) Vacuum extraction. Medscape. Retrieved September 18, 2013 from

http://emedicine.medscape.com/article/271175-overview.• Reid, J. (2007) Neonatal subgaleal hemorrhage. Neonatal Network. 26(4). 219-227.• Schierholz, E., Walker, S.R. (2010) Responding to traumatic birth subgaleal hemorrhage, assessment and

management during transport. Advances in Neonatal Care. 10(6). 311-315.• Tscudy, M.M., Arcara, K.M. (2012) The Harriet Lane Handbook. 19th edition. Elsevier Philadelphia, PA.• Wetzel, E.A., Kingman, P.S. (2012) Subgaleal hemorrhage in a neonate with factor X deficiency following

a non-traumatic cesarean section. Journal of Perinatology. 32. 304-305.