DO NOT USE FOR CLINICAL PRACTICE
Please use current guidelines available on the UHNM intranet for patient treatment
Please use current guidelines available on the UHNM intranet for patient treatment
RECOGNITION AND ASSESSMENT
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
- generalised swelling or boggy consistency of scalp
- 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
- hypovolemic shock
Profound shock can occur rapidly with blood loss into subgaleal space – the blood loss may not be apparent
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
DIFFERENTIAL DIAGNOSIS
- 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
IMMEDIATE TREATMENT
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
RECOGNITION OF HYPOVOLAEMIA
- 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
Consider elective intubation and ventilation for worsening shock – blood is the priority over airway and breathing
CONCOMITANT INJURIES
- 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
SUBSEQUENT MANAGEMENT
- 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