Cephalhaematoma and subgaleal haemorrhage

Overview & Definition

A newborn delivered by vacuum or forceps, or after a long obstructed labour, is noted to have a swelling of the scalp. The question that decides everything is simple: which plane is the blood in? The answer separates a harmless caput from a benign cephalhaematoma from a potentially lethal subgaleal haemorrhage, and it is answered by examining the swelling against the suture lines. ^{[3] [8]}

Caput succedaneum is oedema of the soft tissue of the scalp — subcutaneous, present at birth from the pressure of the presenting part against the cervix, crossing the suture lines, pitting on pressure, and resolving over the first days. It is harmless. Cephalhaematoma is a collection of blood between a skull bone and its periosteum — subperiosteal — confined by the attachments of the periosteum to the suture of that bone, so it does not cross the suture line, is firm and non-pitting, and enlarges over the first hours to days. Subgaleal haemorrhage is blood in the loose areolar tissue beneath the galea aponeurotica — the subaponeurotic space — which is a large potential space extending across the whole vault and down to the nape of the neck, so the swelling is diffuse, crosses the sutures and fontanelles, and can hold a volume of blood large enough to exsanguinate a newborn. ^{[3] [6] [8]}

The clinical importance of each is set by its plane. The subperiosteal space of a single bone is small and tight — a cephalhaematoma is self-limiting and its blood stays localised, the main late consequences being anaemia and hyperbilirubinaemia as the clot is reabsorbed. The subaponeurotic space is enormous by comparison — it has been estimated to hold a substantial fraction of a newborn's blood volume, which is why a subgaleal haemorrhage is the one scalp bleed that can kill. Recognising which plane you are dealing with, and reacting to the systemic signs of blood loss, is the heart of this topic. ^{[3] [4]}

The modern story of these conditions is one of prevention and vigilance. Safer operative vaginal delivery — limits on the number of cup detachments and pulls, abandoning the instrument for a caesarean when delivery does not progress, and alerting the neonatal team whenever a vacuum or forceps has been used — has not abolished subgaleal haemorrhage but has made early recognition the difference between a stable infant and a death. The fellowship candidate is expected to carry both the anatomical reasoning and the disciplined post-instrumental observation protocol. ^{[3] [9] [10]}

References15ShowHide

1. [1]Aziz K Part 5: Neonatal Resuscitation 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics, 2021.PMID 33087555
2. [2]Madar J European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth. Resuscitation, 2021.PMID 33773829
3. [3]Babata K Subgaleal hemorrhage in neonates: a comprehensive review and summary recommendations. J Perinatol, 2025.PMID 39284927
4. [4]Colditz MJ Subgaleal haemorrhage in the newborn: A call for early diagnosis and aggressive management. J Paediatr Child Health, 2015.PMID 25109786
5. [5]Florentino-Pineda I Subgaleal hemorrhage in the newborn infant associated with silicone elastomer vacuum extractor. J Perinatol, 1994.PMID 8014708
6. [6]Reid J Neonatal subgaleal hemorrhage. Neonatal Netw, 2007.PMID 17710955
7. [7]Towner D Effect of mode of delivery in nulliparous women on neonatal intracranial injury. N Engl J Med, 1999.PMID 10580069
8. [8]Pollina J Cranial birth injuries in term newborn infants. Pediatr Neurosurg, 2001.PMID 11641618
9. [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
10. [10]Muraca GM Maternal and neonatal trauma following operative vaginal delivery. CMAJ, 2022.PMID 35012946
11. [11]Liu LY Neonatal Subgaleal Hematoma from Trauma During Vaginal Delivery without Instrument Use. Pediatr Dermatol, 2017.PMID 27981624
12. [12]Kim HM Intracranial hemorrhage in infants with cephalohematoma. Pediatr Int, 2014.PMID 24274929
13. [13]Park SH Surgical treatment of subacute epidural hematoma caused by a vacuum extraction with skull fracture and cephalohematoma in a neonate. Pediatr Neurosurg, 2006.PMID 16714873
14. [14]Watchko JF Identification of neonates at risk for hazardous hyperbilirubinemia: emerging clinical insights. Pediatr Clin North Am, 2009.PMID 19501698
15. [15]Karagol BS A linear fracture and meningitis associated with non-infected cephalohematoma in a neonate. Neuropediatrics, 2010.PMID 21445821