Cephalhaematoma and subgaleal haemorrhage — formative SAQs

SAQ 1 — The deteriorating newborn after a vacuum delivery (10 marks)

A term infant was delivered by vacuum extraction for a prolonged second stage, with three cup detachments and approximately fifteen minutes of total application time. At four hours of age the nurse reports that the scalp looks "full", the infant is pale, the heart rate is 180, and the capillary refill is 4 seconds. On examination there is a diffuse, boggy, fluctuant swelling crossing the suture lines and the anterior fontanelle, with bruising tracking into the upper eyelids and the nape of the neck. [4]

a) What is the diagnosis, and which single clinical feature distinguishes it from a cephalohaematoma? (2 marks) [3]

The diagnosis is a subgaleal (subaponeurotic) haemorrhage with evolving hypovolaemic shock. The single distinguishing clinical feature is that the swelling crosses the suture lines and the anterior fontanelle and tracks into the eyelids and neck — a cephalohaematoma is subperiosteal, confined to one bone, and stops sharply at the suture line. [3] [4]

b) Outline your immediate management, including the specific resuscitation steps and the products you would give. (4 marks) [1]

The immediate priority is airway and breathing, secure intravenous or intraosseous access, and volume resuscitation for hypovolaemic shock. [1]

• Begin with 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, because the problem is red-cell loss. [3]
• Send a haematocrit, coagulation screen, group and crossmatch as the first bolus runs — resuscitation precedes investigation. [1]
• Correct any coagulopathy with fresh frozen plasma 10 to 15 mL/kg, cryoprecipitate, platelets, and vitamin K as guided by the screen. [3]

c) Which factors in the birth history raise the index of suspicion, and why does the mode of delivery matter? (2 marks) [9]

The risk factors in this birth are the vacuum extraction with three cup detachments and a prolonged total application time — each of which raises the risk of subgaleal haemorrhage in a measurable dose-response, because the repeated traction and cup shear the galea and the emissary veins traversing the subaponeurotic space. [9] Vacuum carries a higher risk of subgaleal haemorrhage than forceps for this reason. [4]

d) What is the disposition, and what follow-up is required if the infant survives the acute event? (2 marks) [3]

The infant is retrieved to a tertiary NICU with full monitoring, blood-product support, and access to paediatric surgery. After the acute event, neurodevelopmental follow-up is required, including hearing and vision assessment and developmental surveillance, because survivors of a severe subgaleal bleed with hypoperfusion are at elevated risk of neurodevelopmental impairment. [3]

SAQ 2 — A firm swelling over one bone (10 marks)

At the routine day-two check, a term infant delivered after a long labour (no instrumental delivery) has a firm, well-circumscribed swelling over the right parietal bone that does not pit and stops sharply at the sagittal suture. The infant is pink, alert, and feeding well. The mother asks whether the swelling will cause jaundice. [8]

a) What is the diagnosis, and which feature of the swelling confirms the anatomical plane? (2 marks) [8]

The diagnosis is a right parietal cephalohaematoma. The feature that confirms the plane is that the swelling stops sharply at the sagittal suture — a cephalohaematoma is subperiosteal and confined to a single bone by the periosteal attachment at the suture, so it does not cross the suture line (unlike caput or a subgaleal bleed). [8]

b) Why is observation, rather than aspiration, the correct management? (2 marks) [8]

An uncomplicated cephalohaematoma is observed expectantly because the collection is self-limiting and resolves over weeks. Routine aspiration is avoided because it risks introducing infection and converting a sterile collection into an abscess; aspiration is reserved only for an infected cephalohaematoma. [8]

c) The mother asks about jaundice. Explain why a cephalohaematoma is a recognised risk factor for hazardous hyperbilirubinaemia, and state your monitoring plan. (3 marks) [12]

As the sequestered blood of the cephalohaematoma is broken down and reabsorbed over the first days to weeks, the released haemoglobin drives an unconjugated hyperbilirubinaemia that can cross the phototherapy and even the exchange-transfusion threshold. [12] The monitoring plan is a serial serum bilirubin trended against the gestation- and hour-specific threshold, with phototherapy to threshold and exchange transfusion if exceeded. A large cephalohaematoma is a recognised risk factor for hazardous jaundice. [14]

d) State two further complications to monitor for over the coming weeks, and one investigation to consider at this visit. (3 marks) [12]

The two further complications are late anaemia (from reabsorption of the haematoma blood, sometimes enough to require transfusion) and calcification with skull contour deformity (which usually remodels over months). [12] The investigation to consider at this visit is a skull radiograph to detect an underlying linear or depressed skull fracture associated with the cephalohaematoma, and cranial imaging if there are any neurological signs. [12]