Subgaleal haemorrhage after vacuum — structured SAQ (15 marks)

(a) Most likely diagnosis (2 marks)

• Subgaleal (subaponeurotic) haemorrhage. Boggy, diffuse swelling that crosses suture lines and extends behind both ears, with tachycardia, prolonged capillary refill and pallor in an infant born by a difficult vacuum extraction with cup detachments.^[1][2]
• The suture-crossing is the single bedside feature that distinguishes it from cephalohaematoma (subperiosteal, suture-bound, no systemic compromise).^[1]

(b) Immediate management — first hour (4 marks)

One mark per step. ^[1][2]

• Call for help — neonatal registrar or consultant immediately; this is a medical emergency.
• ABC — airway, breathing, circulation; supplemental oxygen; intubate if work of breathing is excessive.
• Two large-bore cannulae (or umbilical venous access); take bloods including FBC, coagulation, crossmatch early; crossmatched blood on standby.
• Fluid bolus 10 mL/kg isotonic crystalloid, repeat to perfusion; crossmatched blood when available; fresh frozen plasma and vitamin K for coagulopathy; platelets if thrombocytopenic.
• Activate neonatal retrieval to a tertiary centre early.^[1]

(c) Surveillance protocol — RANZCOG C-Obs 28 (4 marks)

One mark per element. ^[1][2]

• Tiered surveillance per RANZCOG C-Obs 28 (Prevention, Detection and Management of Subgaleal Haemorrhage in Neonates) — intensity low, intermediate, or high, set by the perceived risk, which depends on both the birth circumstances (instrumental, with cup detachments, off-axis traction, prolonged application, sequential instruments) and the neonatal condition (any sign of scalp swelling, pallor, tachycardia). This infant is high tier.^[1]
• Heart rate and respiratory rate every 30 to 60 minutes, with trend.
• Head circumference and scalp measurement every 1 to 2 hours — mark the swelling's extent with a skin pen and remeasure; progression is the alarm.
• Serial haematocrit every 2 to 4 hours, with low threshold to image (cranial ultrasound or CT) and to involve the neonatal team.
• Observation for at least the first 6 to 24 hours — the bleed grows over hours, not minutes.^[1]

(d) Interpreting the early haemoglobin (2 marks)

• The early haemoglobin of 165 g/L is misleading and does not exclude significant ongoing haemorrhage. In acute neonatal haemorrhage, equilibration between intravascular and extravascular compartments takes time; the first number may be near the pre-bleed value even when significant loss has occurred.^[1]
• Manage on physiology (tachycardia, prolonged capillary refill, pallor, scalp swelling, progressive enlargement) and the trend of serial haematocrit. The serial haematocrit over hours is the laboratory that confirms the diagnosis.^[2]

(e) Documentation (3 marks)

One mark per item cluster. ^[4][5]

• Indication, instrument, cup or blade size and placement, number of tractions and cup detachments, duration of application, and any off-axis traction.
• Fetal condition at birth, Apgars, cord gases, neonatal examination findings, and the surveillance plan instituted.
• Maternal risk factors (nulliparity, prolonged second stage) and the named decision-maker at each step.
• A complete contemporaneous record is the registrar's defence if the case is later reviewed.^[4]