Neonatal Extracranial Injuries: Cephalohematoma, Caput Succedaneum, and Subgaleal Hemorrhage

A table comparing Cephalohematoma, Caput Succedaneum, and Subgaleal Hemorrhage:

Feature	Cephalohematoma	Caput Succedaneum	Subgaleal Hemorrhage
Location	Between the periosteum and skull bone	Above the periosteum, in the subcutaneous tissue	Between the galea aponeurotica and periosteum
Crosses Suture Lines	No	Yes	Yes
Appearance	Firm, well-defined swelling; appears hours after birth	Soft, pitting edema; present at birth	Diffuse, fluctuant swelling; rapidly increasing head size
Time of Onset	Several hours after birth	Present at birth	Immediately after birth or within hours
Resolution Time	Weeks to months	A few days	Can resolve over weeks but requires immediate intervention
Risk Factors	Instrumental delivery, prolonged labor, large fetal head	Prolonged labor, premature rupture of membranes, malpresentation	Vacuum-assisted delivery, prolonged second stage of labor, prematurity
Complications	Jaundice, anemia, rarely infection	Generally none	Severe anemia, hypovolemic shock, jaundice
Management	Conservative; monitor for complications like jaundice	No treatment needed; resolves spontaneously	Immediate intervention; may require blood transfusions, supportive care for complications
Underlying Cause	Trauma during birth, pressure on skull during delivery	Compression of the head against the cervix or vaginal walls	Shearing forces during vacuum-assisted deliveries, traumatic delivery

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Introduction

Neonatal extracranial injuries are types of birth-related trauma that can occur during delivery. These injuries involve bleeding or fluid accumulation in various layers of a newborn’s scalp and surrounding structures. The most common types of extracranial injuries include cephalohematoma, caput succedaneum, and subgaleal hemorrhage. Each condition has distinct features, risk factors, and underlying causes that healthcare providers must understand for proper diagnosis and management.

1. Cephalohematoma

• Location:

  • Cephalohematoma is a collection of blood between the skull and the periosteum. This space is limited to one cranial bone and does not cross suture lines.

• Clinical Features:

  • Appears as a firm, well-defined swelling several hours after birth.

  • Confined to the affected bone, does not cross suture lines.

  • May take weeks to months to resolve completely.

• Risk Factors:

  • Instrumental Delivery: The use of instruments like forceps or vacuum extraction during delivery increases the risk of cephalohematoma due to the pressure applied to the skull.

  • Prolonged Labor: Extended labor can lead to increased pressure on the infant’s head, contributing to the formation of a cephalohematoma.

  • Primiparous Mothers: First-time mothers are more likely to have prolonged labor or instrumental deliveries, which can increase the risk.

  • Large Fetal Head: A larger-than-average fetal head size can lead to more difficult delivery, increasing the chances of cephalohematoma.

• Causes:

  • Trauma during Birth: The primary cause is trauma to the infant's head during delivery, particularly during instrumental delivery.

  • Pressure on the Skull: As the baby passes through the birth canal, pressure on the skull can cause blood vessels between the skull and periosteum to rupture, leading to cephalohematoma.

• Complications:

  • Jaundice due to the breakdown of red blood cells within the hematoma.

  • Anemia in severe cases.

  • Rarely, infection or calcification of the hematoma.

• Management:

  • Typically conservative, focusing on monitoring for complications such as jaundice and anemia.

  • Aspiration is usually avoided unless there is evidence of infection or other complications.
    

2. Caput Succedaneum

• Location:

  • Caput succedaneum refers to the diffuse swelling of the scalp, located above the periosteum. This swelling crosses suture lines and is often seen on the part of the head that was the presenting part during delivery.

• Clinical Features:

  • Present at birth as a soft, pitting swelling.

  • Extends across suture lines.

  • Typically resolves spontaneously within a few days.

• Risk Factors:

  • Prolonged Labor: Long labor increases the time the infant’s head is subjected to pressure, leading to caput succedaneum.

  • Premature Rupture of Membranes: This condition leads to reduced amniotic fluid, causing increased pressure on the baby’s head during contractions.

  • Malpresentation: Abnormal positions of the baby’s head during delivery (e.g., face or brow presentation) can increase the risk.

  • Instrumental Delivery: The use of forceps or vacuum extraction can exacerbate the formation of caput succedaneum due to the added pressure on the scalp.

• Causes:

  • Compression of the Head: Pressure on the baby's head against the mother's cervix or vaginal walls during delivery causes the swelling characteristic of caput succedaneum.

  • Prolonged Engagement: When the head remains engaged in the birth canal for an extended period, caput succedaneum can develop.

• Complications:

  • Generally, caput succedaneum does not lead to significant complications and resolves on its own without intervention.

• Management:

  • No specific treatment is needed as caput succedaneum usually resolves within a few days post-delivery.
    

3. Subgaleal Hemorrhage

• Location:

  • Subgaleal hemorrhage involves bleeding in the potential space between the galea aponeurotica and the periosteum of the skull. This space can accommodate a large volume of blood, leading to significant swelling and, potentially, hypovolemic shock.

• Clinical Features:

  • Presents as a diffuse, fluctuant swelling that crosses suture lines.

  • Rapid increase in head circumference.

  • May be associated with significant blood loss, leading to hypovolemic shock.

• Risk Factors:

  • Vacuum-Assisted Delivery: The use of vacuum extraction during delivery is the most significant risk factor for subgaleal hemorrhage due to the shearing forces applied to the scalp.

  • Prolonged Second Stage of Labor: Prolonged pushing can increase the risk of subgaleal hemorrhage due to the sustained pressure on the head.

  • Prematurity: Premature infants have more fragile blood vessels, increasing the risk of hemorrhage.

  • Coagulopathy: Any underlying bleeding disorder in the neonate can exacerbate the severity of subgaleal hemorrhage.

• Causes:

  • Shearing Forces: The application of excessive or improper force during vacuum-assisted deliveries can cause the rupture of emissary veins, leading to a subgaleal hemorrhage.

  • Traumatic Delivery: Difficult or traumatic deliveries with significant pressure applied to the scalp can result in bleeding into the subgaleal space.

• Complications:

  • Severe anemia due to significant blood loss.

  • Hypovolemic shock, which is life-threatening and requires immediate intervention.

  • Jaundice due to the breakdown of blood in the hemorrhage.

• Management:

  • Immediate medical intervention is crucial, focusing on stabilizing the infant, managing blood loss, and preventing shock.

  • Blood transfusions may be necessary, along with supportive care for complications like jaundice.
    

Visual Summary

The accompanying image provides a clear visual representation of these conditions:

• Caput Succedaneum: Swelling occurs above the periosteum, crossing suture lines.

• Cephalohematoma: Blood accumulates beneath the periosteum, confined to one cranial bone and does not cross suture lines.

• Subgaleal Hemorrhage: Blood collects in the subgaleal space, extending across the scalp, and can lead to severe complications.
  

Conclusion

Understanding the risk factors, causes, and clinical presentations of cephalohematoma, caput succedaneum, and subgaleal hemorrhage is essential for proper management and care of newborns who experience these birth-related injuries. Early recognition and appropriate treatment can significantly improve outcomes and reduce the risk of complications.