1. 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

2. 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

3. 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.

4. Female Pelvis

5. Female Pelvis

10. Anatomy of the Scalp

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

12. 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

13. Anatomy of the Scalp
Caput succedaneum

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

17. 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.

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

19. 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)

20. Anatomy of the Scalp
Cephalo-hematoma

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

22. 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.

26. Back
Front

28. 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”

30. 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.

31. Anatomy of the Scalp
Subgaleal hemorrhage

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

33. Subgaleal Hemorrhage
Occurrence: RARE 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

34. 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

35. Anterior border
Posterior border
Lateral border

36. Anterior border
Posterior border
Lateral border

37. 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

38. Anatomy of the Scalp Caput succedaneum Subgaleal hemorrhage
Cephalo-hematoma

39. 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

40. 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
ml or more

41. 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.