Subgaleal Hemorrhage: Definition, Risk Factors, Differences, Monitoring, and Management, Lecture notes of Neurological Basis of Behavior

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Subgaleal

Hemorrhage

Updated October 2014

OVERVIEW

• Review the definition of subgaleal hemorrhage
• Review the risk factors for developing subgaleal hemorrhage
• Review the differences between subgaleal hemorrhage,

cephalohematoma and caput

• Describe the revised monitoring parameters for BCW new

policy

Picture for Definition

Subgaleal hemorrhages are characterized by a collection of fluid

that fluctuates when palpated and may shift with repositioning of

the head.

Incidence

 Rare

 Potentially lethal condition

 More prevalent following a difficult

vacuum or forceps-assisted birth.

 The prevalence of moderate-to-severe

SGH is reported as 1.5 per 10,000 births.

 Up to 25% of babies who require

neonatal intensive care for this condition

can die.

Risk Factors

At Risk Newborns:

 Any vacuum delivery, (in particular with more than 3 pulls

or pop-offs)

 Any delivery where a vacuum extraction has been

attempted

 Eg: includes failed vacuum delivery that results in c-

section delivery

 Delivery where vacuum delivery has been attempted and

another instrument, such as forceps, has been used as

the final method of delivery

 Any rotational forceps delivery

Signs and symptoms of SGH

May notice immediately or over the next several hours

following delivery.

1. Diffuse fluctuating swelling of the head that crosses

suture lines, shifts dependently when the infant's head is

repositioned and indents easily on palpation.

2. Increasing Head Circumference

3. Evidence of hypovolemia (lethargy, pallor, poor perfusion,

tachycardia, increased respiratory rate, decreased urinary

output, hypotonia)

4. Prolonged bleeding (late sign)

5. Seizures (not usually until advanced hemorrhage)

Diagnosis

 Diagnosis of SGH is clinical. The scalp is

boggy (feels like a water balloon, fluid is

firm to fluctuant with ill defined borders,

may have crepitus or waves and shifts

dependently when the infant’s head is

repositioned). SGH may be

misdiagnosed as cephalohematomas or

caput succedaneum.

Cephalhematoma vs Caput

 Cephalhematoma is the collection of blood

under the periosteum and does not cross the

suture lines. Cephalhematomas are firm

masses that will resolve in 2 weeks to 6

months.

 Caput is localized scalp edema that is the

result of venous congestion from the

pressure of the head applied to the dilating

cervix. The edema can cross the suture lines.

Caput does not increase in size over time

and resolves several days after birth.

MONITORING

PARAMETERS FOR SGH

Newborns at risk for SGH

 Can remain with their mother as long as

their vital signs are normal and the infant

is not demonstrating any signs of

distress.

 Those infants should be observed for

symptoms for 24 hours before discharge.

Assessments to include close

observation and documentation of the

following:

 Vital Signs (Heart Rate, Respirations, Temperature)

 Colour, perfusion and appearance of the scalp (DO NOT use hats/bonnets)

 Assess for bogginess of the head

 Visual inspection and manual palpation of the head including the scalp

 Behavioural State

 Tone

No measurement of head

circumference required by RN

Early Identification

 Identification

 Screen and monitor all at- risk newborns as recognition and supportive care can improve survival and outcome

 No hats or bonnets

 Investigations:

 CBC, hematocrit, hemoglobin should be performed as soon as possible and should be monitored every 4–8 hours.  Coagulation screen (INR, PTT, PTT, fibrinogen, d- dimers) every 4-8 hours.  CT scan or MRI of the head. MRI scan is the preferred method of imaging  Radiographs of the skull can also be useful to identify underlying fractures

Inspection