Cephalhaematoma and subgaleal haemorrhage — formative SAQs

SAQ 1 — The deteriorating newborn after a vacuum delivery (10 marks)

A term infant was delivered by vacuum extraction for a prolonged second stage, with three cup detachments and approximately fifteen minutes of total application time. At four hours of age the nurse reports that the scalp looks "full", the infant is pale, the heart rate is 180, and the capillary refill is 4 seconds. On examination there is a diffuse, boggy, fluctuant swelling crossing the suture lines and the anterior fontanelle, with bruising tracking into the upper eyelids and the nape of the neck. [4]

a) What is the diagnosis, and which single clinical feature distinguishes it from a cephalohaematoma? (2 marks) [3]

The diagnosis is a subgaleal (subaponeurotic) haemorrhage with evolving hypovolaemic shock. The single distinguishing clinical feature is that the swelling crosses the suture lines and the anterior fontanelle and tracks into the eyelids and neck — a cephalohaematoma is subperiosteal, confined to one bone, and stops sharply at the suture line. [3] [4]

b) Outline your immediate management, including the specific resuscitation steps and the products you would give. (4 marks) [1]

The immediate priority is airway and breathing, secure intravenous or intraosseous access, and volume resuscitation for hypovolaemic shock. [1]

• Begin with a 10 mL/kg bolus of isotonic crystalloid (normal saline), repeated as guided by perfusion and haematocrit. [3]
• For ongoing major haemorrhage, give early type-O negative blood rather than further clear fluid, because the problem is red-cell loss. [3]
• Send a haematocrit, coagulation screen, group and crossmatch as the first bolus runs — resuscitation precedes investigation. [1]
• Correct any coagulopathy with fresh frozen plasma 10 to 15 mL/kg, cryoprecipitate, platelets, and vitamin K as guided by the screen. [3]

c) Which factors in the birth history raise the index of suspicion, and why does the mode of delivery matter? (2 marks) [9]

The risk factors in this birth are the vacuum extraction with three cup detachments and a prolonged total application time — each of which raises the risk of subgaleal haemorrhage in a measurable dose-response, because the repeated traction and cup shear the galea and the emissary veins traversing the subaponeurotic space. [9] Vacuum carries a higher risk of subgaleal haemorrhage than forceps for this reason. [4]

d) What is the disposition, and what follow-up is required if the infant survives the acute event? (2 marks) [3]

The infant is retrieved to a tertiary NICU with full monitoring, blood-product support, and access to paediatric surgery. After the acute event, neurodevelopmental follow-up is required, including hearing and vision assessment and developmental surveillance, because survivors of a severe subgaleal bleed with hypoperfusion are at elevated risk of neurodevelopmental impairment. [3]