Subgaleal Hematoma in Newborn

A subgaleal hematoma is a collection of blood that forms after a subgaleal hemorrhage, or brain bleed. The bleed occurs in the space between a baby’s skull and their skin. When the subgaleal hemorrhage is not actively bleeding, it can form a hematoma (or collection of partially solid blood). This condition is most commonly caused by the use of vacuum extractors and forceps during difficult vaginal deliveries.

Subgaleal hemorrhages can cause substantial blood loss, which is particularly dangerous for a newborn. In 25% of cases, subgaleal hemorrhages are fatal. If the condition is appropriately diagnosed and treated with transfusions, many babies recover within just a few weeks. A failure to properly diagnose and treat a subgaleal hemorrhage is often a sign of medical negligence.

At the Birth Injury Lawyers Alliance (BILA), we are dedicated to helping families and children seek justice for losses caused by medical negligence. Our team of highly skilled birth injury lawyers offers free initial consultations and will never charge a fee unless we recover money for you. Reach out today to schedule a free consultation with a birth injury lawyer in your province.

What Is a Subgaleal Hematoma?

A subgaleal hematoma is an accumulation of blood on a baby’s skull. It is caused by a subgaleal hemorrhage, or a brain bleed, which is active bleeding between a baby’s skull and skin on the cap. This blood accumulates within the layers of soft tissue on the head, between the connective tissue (galea aponeurotica) and membrane tissue (periosteum) covering a newborn’s skull. 

This condition is referred to as a subgaleal hemorrhage when it is still bleeding, and a hematoma after the bleeding has concluded and the accumulated blood has coagulated into a partially solid form. Throughout this post, we will primarily describe a subgaleal hemorrhage, as that is what causes the hematoma that forms in the same subgaleal area.

This condition occurs when the veins that go through an opening in a baby’s scalp (foramen) separate from the tissue and rupture. This often occurs during a difficult vaginal delivery, particularly if an assistive device (such as a vacuum or forceps) is used.

Subgaleal hemorrhages are relatively rare, occurring in approximately 4 out of every 10,000 vaginal deliveries where tools are not used. If tools are used, then the rate increases to approximately 60 out of 10,000 deliveries.

There are signs and symptoms of a subgaleal hemorrhage that may appear shortly after birth. This may include:

• Fast heart rate (tachycardia)
• Bruising on the skin
• Pale skin tone (pallor)
• Low blood pressure
• Lower levels of hemoglobin and hematocrit in the blood due to blood loss
• “Boggy” cranial swelling, or swelling that has a liquid movement.

In approximately a quarter of all subgaleal hemorrhage cases, life-threatening symptoms may occur. This includes:

• Extensive fluid loss caused by an inability of the heart to pump enough blood (hypovolemic or hemorrhagic shock)
• Respiratory distress
• Excessive internal bleeding or clotting (coagulopathy)
• Lack of oxygen to the brain during birth (intrapartum hypoxia)
• Organ failure

Subgaleal hemorrhages can be life-threatening because they can cause a baby to lose anywhere from 20 to 40% of their blood volume. These bleeds can be treated and cured with prompt treatment. They can often resolve within 2 to 3 weeks with appropriate treatment.

What Causes Subgaleal Hemorrhage in Newborns?

Subgaleal hemorrhages occur when veins rupture in the subgaleal space between a baby’s skin and scalp bone. These veins are known as emissary veins, as they pass through a connective opening of the scalp. The veins can break during a vaginal delivery, causing a hemorrhage. In essence, they are caused by trauma to the head during labour and delivery that severs the veins in a baby’s head.

A subgaleal hemorrhage only occurs during a vaginal delivery. In most cases, they happen after an assisted delivery where a vacuum extractor or forceps are used to assist the baby out of the birth canal during a difficult labour process. Tools are most often used in cases where:

• A baby has a particularly large size, known as macrosomia
• A baby’s head or body cannot fit through the mother’s pelvis (cephalopelvic disproportion)
• The baby is not coming down the birth canal safely (fetal dystocia)
• Labour does not progress after more than 20 hours (prolonged labour)
• Labour progresses too quickly, known as precipitous labour

All of these factors increase the likelihood that an assisted delivery may be necessary. It is also more common in first-time pregnancies and when the baby is a boy.

While subgaleal hemorrhages can occur in any difficult vaginal birth, they are most common in assisted deliveries, particularly with the use of a vacuum extractor. This tool is connected to an infant’s head to assist with the birthing process. 

Unfortunately, the suction of the vacuum can pull a baby’s skin on the scalp away from the skull, loosening the connective tissue in the subgaleal space. This can allow blood to accumulate outside of a baby’s skull, ultimately forming a hematoma. If a baby hemorrhages too much blood, it could be life-threatening.

When used properly, vacuum extractors can be a safe tool to assist in challenging vaginal deliveries. However, if the suction cup is placed on the wrong part of the baby’s head, if too much force or pressure is used, if the cup is suctioned for an extended period of time, or if there are too many attempts made with a vacuum extractor, it can cause a potentially dangerous subgaleal hemorrhage. Similarly, improper use of tools like forceps can break the blood vessels in a baby’s skull and cause a brain bleed.

Treatment and Long-Term Prognosis for Newborns with Subgaleal Hematomas

After birth, a doctor or other healthcare provider should carefully check your newborn to make sure that they are healthy. This should include checking for symptoms of a subgaleal hematoma, like pale skin, swelling of the scalp, and low blood pressure. If they suspect a subgaleal hemorrhage/hematoma, they will order an imaging test (such as an ultrasound, CT scan, MRI, or X-ray) to confirm the diagnosis and examine the hemorrhage.

In vacuum or forceps delivery cases, your newborn should be monitored in the nursery even if they do not have immediate physical symptoms of a subgaleal hematoma. The signs of this type of hemorrhage do not always appear immediately, so close monitoring is essential to watch for any issues in cases where a baby is at higher risk for this type of birth injury. A subgaleal hematoma may become apparent within anywhere from 1 to 72 hours after birth.

If a subgaleal hematoma is diagnosed, then immediate medical treatment is required to stem the blood loss. This includes treatments to restore blood volume with blood and plasma transfusions. Known as volume resuscitation, an infant will receive liquids that include packed red blood cells to restore the oxygen-carrying function of the blood, fresh frozen plasma, and saline. This will take place in the neonatal intensive care unit (NICU). 

While your baby is getting transfusions, the medical team will monitor their blood levels carefully to make sure that their hemoglobin and hematocrit counts are normal. They will also check for swelling by measuring your baby’s head circumference. In more severe cases, transfusions simply are not adequate to treat the hemorrhage. In this situation, emergency surgery may be necessary to stop the internal bleeding.

With prompt treatment, most subgaleal hematomas resolve within a few weeks. Treatment is successful in approximately 75% of all subgaleal hemorrhage cases. In approximately 10 to 25% of subgaleal hemorrhage cases, the infant will die due to severe internal bleeding.

If not treated promptly, a subgaleal hematoma can cause many long-term complications. This may include:

• Neonatal encephalopathy
• Seizures
• Brain damage
• Hypoxic-ischemic encephalopathy (HIE)
• Periventricular leukomalacia
• Cerebral palsy
• Developmental disabilities such as autism
• Kernicterus

These conditions can be caused by blood loss, which is linked to oxygen deprivation. When a newborn does not get enough oxygen during or after birth, it can cause brain damage. Many children with these conditions suffer from disabilities that require a lifetime of care.

In many cases, careful monitoring of newborns, particularly those at higher risk of developing a subgaleal hematoma, is the key to preventing more serious outcomes (including death). If a doctor does not properly assess a newborn and intervene with treatment, then it can cause far more serious issues. Because treatment does work in 75% of cases, it is critical that medical staff appropriately evaluate newborns and treat them with fluid transfusions to prevent further harm.

Subgaleal hemorrhages and subgaleal hematomas are often the result of medical negligence due to the improper use of tools like vacuum extractors and forceps. They can also be a sign that a doctor failed to intervene early enough during a difficult vaginal birth to perform a cesarean section (c-section). If your baby was diagnosed with a subgaleal hematoma, it could be an indication that your obstetrician did not meet the standard of care for your labour and delivery.

Similarly, a failure to diagnose and treat a subgaleal hemorrhage immediately after birth is also a form of medical negligence. This type of negligence may lead to tragic results, including long-term damage due to blood loss or even death. If your baby has been diagnosed with a birth injury due to a subgaleal hemorrhage and/or hematoma, you may be able to pursue legal action.

Help for Families After a Subgaleal Hematoma

Subgaleal hemorrhages are caused by trauma during a vaginal delivery. While they are not preventable in every case, they are often caused by medical negligence, such as the improper use of vacuum extractors or forceps, or failure to intervene early. If the condition is not diagnosed and treated to limit or avoid excessive blood loss, a baby might suffer severe injuries or may even die.

If your baby has been diagnosed with subgaleal hematoma or another birth injury that you believe may have been caused by medical negligence, a birth injury lawyer can advise you of your legal options. For assistance with subgaleal hemorrhages or other types of birth injury claims, call BILA today at 1-800-300-BILA or fill out our online contact form to schedule a free initial consultation with a lawyer in your province.

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