1. Max Brinsmead PhD FRANZCOG July 2011 S UBGALEAL H AEMATOMA IN THE N EONATE

2. R ESOURCES  RANZCOG Statement July 2009

3. D EFINITION  Bleeding within the potential space between the scalp aponeurosis and periosteum  From rupture of emissary veins which connect dural sinuses and scalp veins  Needs to be distinguished from...  Caput succedaneum (fluid only in extraponeutic tssues)  Cephalhaematoma which is bleeding between periosteum and the cranial bones

4. S UB G ALEAL H AEMORRHAGE IS IMPORTANT BECAUSE...  Up to 250 ml of blood can collect in this space  With only a 1 cm increase in scalp thickness  This can be 50 – 75% of an infant’s blood volume  Losses of this order cause hypovolaemic shock, coagulopathy and death  Of babies admitted to NICU with this condition the mortality is 12 – 25%

5. W HO IS AT R ISK ?  Occurs at a rate of one in every 1666 after spontaneous delivery  But up to 1:5 after ventouse  Odds Ratio (OR) for Vacuum Delivery is 7.17 (CI 5.43 – 10.25)  OR for failed vacuum delivery is 16.4  OR for Forceps Delivery is 2.66 (CI 1.78 – 5.18)

6. C LINICAL F EATURES  Low 5-min Apgar for an at risk baby should raise clinical suspicion  Tachyopnoea, tachycardia, pale & listless or irritable cry  Generalised scalp swelling and laxity scalp  Ballotable mass that extends beyond scalp sutures May extend from orbit to ears and down the neck  Serial head measures may be used  But intervention may be required long before this is documented

7. H OW TO A VOID S UBGALEAL H AEMORRHAGE  Avoid ventouse before 34 completed weeks  And cautiously before 36 weeks  Also for babies with suspected bleeding disorder  Correct cup application  To the flexion point on the head  Steady traction only with contractions & maternal effort  Progress with every pull  Delivery completed (or close to completion) within 3 pulls

8. H OW TO A VOID S UBGALEAL H AEMORRHAGE (2)  The delivery should be complete (or close to completion) within 20 minutes of suction  Consider Caesarean after 15 minutes with no progress  Detachment is not a “safety feature” of the instrument and should be avoided  Abandon the attempt after two (max 3) detachments (technical problems exempted)  Give Vitamin K asap after birth to all infants (and high risk babies in particular)

9. M ANAGEMENT OF S USPECTED S UBGALEAL H AEMORRHAGE  Appropriate observations of all babies after instrumental delivery  Avoid hats & bonnets (or remove them frequently)  For a high risk infant i.e. After any difficult ventouse  Perform cord blood gases, pH, Haematocrit and Platelet count  Hourly obs for 12 hours  Pulse oximetry desirable  Do not delay treatment with attempted imaging  Aggressive resuscitation with crystalloids and blood  Involve paediatrician. Will require NICU

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