Lumps & Bumps on the Newborn Head. When should I worry? Joseph A. Garcia-Prats, M.D. Medical Director, Arnold J. Rudolph NICU Professor, Pediatrics & Ethics Baylor College of Medicine

Objectives Review anatomy of newborn head Briefly review the process of labor Review anatomy of newborn head Identify abnormal extra cranial findings Discuss the most common extra cranial lumps and bumps: Caput succedaneum, cephalohematoma, subgaleal hemorrhage

Process of Labor Goal of labor is to prepare the cervix and pelvic bones to expel the uterine contents Describe three phases: latent, active, descent Approximately 9%- 30% of women have non-vaginal deliveries in the U.S.

Female Pelvis

Female Pelvis

Anatomy of the Scalp

Scalp Brain Skull bone Dura/pia/arachnoid Galea aponeurotica Periosteum Skull bone Dura/pia/arachnoid Brain

Caput Succedaneum Definition: a lesion characterized by a vaguely demarcated area of edema over that portion of the scalp that was the presenting part during a vertex delivery Etiology: extravasation of serum and/or blood from the higher pressures of the uterus and vaginal wall on those areas of the fetal head that border the caput that accumulates over the periosteum

Anatomy of the Scalp Caput succedaneum

Scalp Brain Skull bone Dura/pia/arachoid Periosteum Edema Blood Edema Galea aponeurotica Periosteum Skull bone Dura/pia/arachoid Brain

Caput Succedaneum Occurrence rate: very common Clinical manifestation: soft swelling usually a few millimeters thick (although it may be much thicker) and may be associated with overlying petechiae, purpura or ecchymosis. Extends beyond suture lines.

Caput Succedaneum Treatment: none Resolution: hours to 1-2 days Complications: none

Cephalohematoma Definition: bleeding below the periosteum of the skull Etiology: mechanism of of the bleeding is not exactly known (may occur in uncomplicated vaginal deliveries or in newborns delivered by caesarian section)

Anatomy of the Scalp Cephalo-hematoma

Scalp Brain Skull bone Dura/pia/arachnoid Periosteum Suture Suture Galea aponeurotica Periosteum Suture cephalohematoma Suture Skull bone Dura/pia/arachnoid Brain

Cephalohematoma Occurrence: 0.41% - 2.5% of deliveries Noted more often in: (1) males, (2) on right side, (3) newborns delivered vaginally. Bilateral involvement: 15% Diagnosis: “fluid like accumulation” best appreciated at 6-24 hours after delivery; does not transilluminate; boundaries are the suture lines.

Back Front

Cephalohematoma Resolution: 2-8 weeks with a “crater like ridge” noted as it resolves Complications: Hyperbilirubinemia, anemia, infection, calcification, osteomyelitis, skull fracture (5 % occurrence with unilateral and 18% with bilateral cephalohematoma – rarely associated morbidity) Treatment: “Expectant”

Subgaleal Hemorrhage Definition: extracranial bleeding from under the scalp which may become massive and life threatening Etiology: rupture of emissary veins with blood accumulating between the epicranial aponeurosis of the scalp and the periosteum.

Anatomy of the Scalp Subgaleal hemorrhage

Scalp Brain Skull bone Dura mater Periosteum Galea aponeurotica Muscle attach Muscle attach Subgaleal hemorrhage Periosteum Skull bone Dura mater Brain

Subgaleal Hemorrhage Occurrence: RARE -- 1.5 per 10,000 births to 1 per 30,000 births. Appears to be an increased occurrence with vacuum extraction, forceps delivery, but may also be seen in spontaneous deliveries. Contributing factors may be inappropriate placement and/or failed vacuum extraction

Subgaleal Hemorrhage Clinical manifestations: Ill-defined borders,firm to fluctuant, may have fluid waves Potential space includes the limits of: orbital margins back to the nuchal ridge, laterally temporal facia. “Football helmet” like location

Anterior border Posterior border Lateral border

Anterior border Posterior border Lateral border

Subgaleal Hemorrhage Treatment: Close monitoring of vital signs looking for increasing FOC and signs of hypovolemia. Supportive care very important which includes: volume replacement, monitoring for DIC, factor replacement Resolution: 2-3 weeks Complications: Encephalopathy, intracranial pathology(ICH, edema, skull fracture), DIC, jaundice

Anatomy of the Scalp Caput succedaneum Subgaleal hemorrhage Cephalo-hematoma

Scalp Brain Skull bone Dura mater Periosteum Suture Suture Edema Edema Blood Scalp Blood Edema Edema Galea aponeurotica Muscle attach Muscle attach Subgaleal hemorrhage Periosteum Suture Suture Cephalohematoma Skull bone Dura mater Brain

Feature Caput Cepahlo-hematoma Subgaleal hemorrhage Location Crosses sutures Distinct margins; sutures are limits Crosses sutures; “football helmet-like” Findings Firm edema-vaguely demarcated Initially firm; distinct margins; fluctuant > 48 Diffuse, shifts depedently, fluid like Timing Noted at birth hours -- days after birth At birth or hours later Volume of blood None to very little 10 – 40 ml 50-100 ml or more

In Conclusion Understanding the anatomy of the tissues surrounding the skull makes it easier to distinguishing the different “lumps and bumps”. Armed with this knowledge the perinatal health care provider is in a better position to identify patients at risk for complications associated with these lesions.