Diffuse scalp swelling and pallor after vacuum delivery — subgaleal haemorrhage

Clinical information for the examiner

Setting: Postnatal ward, four hours of life. Term infant (39 weeks, 3.4 kg) delivered by vacuum extraction after a prolonged second stage; two cup detachments occurred during the delivery. Vitamin K was given intramuscularly at birth. [9]

On your arrival:

• Heart rate 180 bpm (was 130), respiratory rate 70, SpO₂ 94% in air, capillary refill 4 seconds, the infant is pale. [4]
• Scalp: a diffuse, boggy, fluctuant swelling over the whole vault that crosses the sagittal and lambdoid sutures and the anterior fontanelle, with ecchymosis tracking into the upper eyelids and the nape of the neck. [3]

Task 1 — Focused assessment and diagnosis (3 marks)

The candidate should perform an ordered assessment. [3] [8]

1. Inspect and palpate the swelling: map it to the suture lines — confirm it crosses the sagittal and lambdoid sutures and the anterior fontanelle, is diffuse, boggy and fluctuant, and tracks into the eyelids and neck. [3]
2. Assess the perfusion: colour (pallor), capillary refill (4 seconds, prolonged), heart rate (180, tachycardia), blood pressure. [4]
3. Take the birth history: vacuum extraction, two cup detachments, prolonged second stage — each raises the risk of subgaleal haemorrhage. [9]

Pass criterion: candidate identifies subgaleal haemorrhage from the suture-crossing boggy swelling and the signs of shock, and states the suture line as the discriminator from a cephalohaematoma. [3]

Task 2 — Emergency resuscitation (4 marks)

Resuscitate before you investigate. [1]

• Secure intravenous or intraosseous access early. [1]
• Begin a 10 mL/kg bolus of isotonic crystalloid (normal saline), repeated as guided by perfusion and haematocrit. [3]
• For ongoing major haemorrhage, give early type-O negative blood rather than further clear fluid. [3]
• Send haematocrit, coagulation screen, group and crossmatch as the first bolus runs. [1]

Pass criterion: candidate states resuscitation before investigation, the 10 mL/kg crystalloid bolus, and the early switch to blood for ongoing major haemorrhage. [1] [3]

Task 3 — Coagulation correction and disposition (3 marks)

• Correct any coagulopathy with fresh frozen plasma 10 to 15 mL/kg, cryoprecipitate, platelets, and vitamin K as guided by the screen. [3]
• Retrieve to a tertiary NICU with full monitoring, blood-product support, and access to paediatric surgery. [4]
• Arrange cranial imaging if there are neurological signs or if the haematocrit falls out of proportion to the scalp bleed (suspect an intracranial component). [12]

Pass criterion: candidate names the coagulation products with doses, the tertiary retrieval, and the indication for cranial imaging. [3] [12]

Task 4 — Prevention and counselling (2 marks)

Prevention: disciplined operative vaginal delivery — limits on cup detachments and pulls, and a neonatal alert for every vacuum or forceps birth to trigger the structured observation protocol. [9]

Counselling: honest disclosure of the mechanism (shearing of the emissary veins by the instrument), the acute management, and the prognosis (good with early recognition, worse with delay or coagulopathy). [4]