Neonatal Subgaleal Hematoma
A subgaleal hematoma (SGH), also known as a subgaleal hemorrhage, is a serious complication that occurs when blood accumulates outside of the baby’s skull (extracranially) (1). The accumulation occurs in the space between the periosteum of the skull (the membrane that covers the skull) and the scalp aponeurosis (the fibrous tissue that covers over top of that membrane), where there is loose areolar tissue. SGH occurs in roughly 0.04% of spontaneous vaginal deliveries and 0.59% of vacuum-assisted deliveries.
Subgaleal hematomas have the potential to drain a significant amount of blood from the newborn, putting the baby at risk of injuries including neonatal encephalopathy (brain damage), seizures, or even death. The reported mortality rate in infants with SGH is 22.8% (2). Due to the high-risk nature of this condition, it is crucial that SGH be identified and treated promptly to avoid and/or limit damage to the baby.
Causes of subgaleal hematoma
Subgaleal hemorrhages are caused by trauma to the head during labor and delivery, which results in the severing of emissary veins, located between the dural sinuses that cover the skull and the scalp (1). Most commonly, this trauma is caused by the pulling, dragging, or compressing of a baby’s head through the mother’s pelvis during delivery.
Subgaleal hematoma is most often caused by the use of vacuum extractors and forceps during delivery (3). Vacuum extractors can cause head trauma when the physician places the suction cup on the wrong part of the baby’s head, applies too much pressure or force, keeps the cup suctioned for an extended period of time, or makes too many attempts at using the vacuum extractor, called pop-offs. When vacuum extractors or other assistive tools like forceps are used improperly, they can cause bleeding within the subgaleal space (between the scalp and the skull).
Because of the associated risks, vacuum- and forceps-assisted deliveries are often discouraged. To learn more about when it is appropriate to use these tools during delivery, visit this page.
Risk factors for subgaleal hematoma
Certain attributes present during pregnancy may make a neonate more susceptible to subgaleal hemorrhaging. These risk factors must be taken into consideration as doctors make decisions regarding the pregnancy, labor, and delivery. Some of the most prominent risk factors for subgaleal hematoma in newborns are (2):
- Primiparity (first-time pregnancy)
- Male sex
- Prolonged second stage of labor
- Premature birth
- Cephalopelvic disproportion (CPD)
Signs of a subgaleal hematoma
Subgaleal bleeding poses a serious threat of blood loss for infants, so it is critical that doctors rapidly identify this condition in order to provide proper treatment. Infants who underwent a difficult or assisted delivery must have especially close monitoring. When treating these patients, physicians should (1):
- Carefully monitor vital signs for symptoms of shock (elevated heart rate, decreased blood pressure, etc.)
- Serially assess hematocrit levels
- Test bilirubin levels
- Pay close attention to pallor, tone, and respiratory distress
If physicians follow the above monitoring guidelines, they will be able to clearly identify infants suffering from a subgaleal hemorrhage. These infants may present with the following attributes (1):
- Palpable swelling on the head, which may shift with movement and expand over time due to additional bleeding.
- Decreasing blood pressure
- Diminished tone
- Respiratory distress
Treatment for subgaleal hematoma
Newborns who underwent difficult vacuum extraction or forceps delivery should be treated with a minimum of 8 hours of observation regardless of need for resuscitation or Apgar score (3). Their vital signs should also be assessed hourly. Head examinations should be done hourly if there is a concern about head swelling. All of these actions will help with early detection and diagnosis of hemorrhage.
Newborns diagnosed with subgaleal hematomas must be treated immediately in order to prevent any further damage (1).
Treatment for a subgaleal hematoma is aimed at resolving the symptoms of blood loss and assuring that the infant returns to a stable condition. This often includes volume resuscitation and blood transfusions to correct ongoing bleeding (1, 3). During volume resuscitation, liquids are restored to the infant in the form of packed red blood cells (to help restore the oxygen-carrying function of blood), normal saline, and fresh frozen plasma.
Once physicians make choices about transfusion, they must continue to monitor the patient. It is important to frequently assess bilirubin levels to make sure the patient is not suffering from hyperbilirubinemia (3). Additionally, physicians should administer blood studies to ensure that the newborn is not suffering from any type of coagulopathy (bleeding disorder) as coagulopathies may be present alongside subgaleal bleeding. If coagulopathy is present, it should be treated according to the specific protocol.
Long-term outcomes for children with subgaleal hematoma
When a subgaleal hematoma is not recognized or treated promptly, it can lead to long-term negative outcomes, which can include:
- Neonatal encephalopathy
- Brain damage
- Hypoxic-ischemic encephalopathy (HIE)
- Periventricular leukomalacia
- Cerebral palsy
- Developmental disabilities
- Kernicterus (brain damage from mismanaged bilirubin issues/jaundice)
Birth injury attorneys helping children with subgaleal hemorrhaging
At ABC Law Centers (Reiter & Walsh, P.C.), our dedicated attorneys represent victims of birth injury every day, helping clients obtain compensation for medical expenses and care to secure their child’s future. With over 130 years of joint legal experience, our team has the education, qualifications, results, and accomplishments necessary to succeed. If your loved one was diagnosed with a subgaleal hematoma/hemorrhage (SGH) and suffers from damage or injury due to this, we encourage you to reach out for a free legal consultation. We do not charge a fee for any of our legal process until we win!
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The information presented above is intended only to be a general educational resource. It is not intended to be (and should not be interpreted as) medical advice.
- McKee-Garrett, T. M. (2017, October 31). Neonatal birth injuries. Retrieved April 6, 2019, from https://www.uptodate.com/contents/neonatal-birth-injuries
- Plauché WC. Subgaleal Hematoma: A Complication of Instrumental Delivery. JAMA. 1980;244(14):1597–1598. doi:10.1001/jama.1980.03310140055031
- Davis D. J. (2001). Neonatal subgaleal hemorrhage: diagnosis and management. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 164(10), 1452–1453.