Paeds Cases · fetal-neonatal-and-perinatal
Diffuse scalp swelling and pallor after vacuum delivery — subgaleal haemorrhage
OSCE on a term newborn delivered by vacuum extraction who develops a diffuse boggy scalp swelling with pallor and tachycardia, testing the suture-line discriminator, the recognition of subgaleal haemorrhage, the resuscitate-before-investigate principle, coagulation correction, and the prevention and counselling bundle.
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Target exams
MRCPCH ClinicalRACP DCERCPSC Pediatrics
Prompt
A term infant delivered by vacuum extraction for prolonged second stage, with two cup detachments, develops a diffuse boggy scalp swelling crossing the suture lines and fontanelle, with pallor, a heart rate of 180 and a capillary refill of 4 seconds; the candidate must perform the focused assessment, state the diagnosis and the discriminator, decide on immediate resuscitation before investigation, describe the fluid and blood-product management, correct the coagulopathy, and state the prevention and counselling bundle.
Clinical information for the examiner
Setting: Postnatal ward, four hours of life. Term infant (39 weeks, 3.4 kg) delivered by vacuum extraction after a prolonged second stage; two cup detachments occurred during the delivery. Vitamin K was given intramuscularly at birth. [9]
On your arrival:
- Heart rate 180 bpm (was 130), respiratory rate 70, SpO₂ 94% in air, capillary refill 4 seconds, the infant is pale. [4]
- Scalp: a diffuse, boggy, fluctuant swelling over the whole vault that crosses the sagittal and lambdoid sutures and the anterior fontanelle, with ecchymosis tracking into the upper eyelids and the nape of the neck. [3]
References6ShowHide
- [1]Aziz K Part 5: Neonatal Resuscitation 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics, 2021.PMID 33087555
- [3]Babata K Subgaleal hemorrhage in neonates: a comprehensive review and summary recommendations. J Perinatol, 2025.PMID 39284927
- [4]Colditz MJ Subgaleal haemorrhage in the newborn: A call for early diagnosis and aggressive management. J Paediatr Child Health, 2015.PMID 25109786
- [8]Pollina J Cranial birth injuries in term newborn infants. Pediatr Neurosurg, 2001.PMID 11641618
- [9]Ghidini A Neonatal complications in vacuum-assisted vaginal delivery: are they associated with number of pulls, cup detachments, and duration of vacuum application? Arch Gynecol Obstet, 2017.PMID 27677283
- [12]Kim HM Intracranial hemorrhage in infants with cephalohematoma. Pediatr Int, 2014.PMID 24274929