Brain Bleeds in a Baby: Subgaleal Hemorrhages

A subgaleal hematoma, or subgaleal hemorrhage, is an accumulation of blood outside of a baby’s skull. This type of brain bleed 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 connective tissue. Subgaleal hemorrhages occur in roughly 0.04% of spontaneous vaginal deliveries and 0.59% of vacuum-assisted deliveries.

Subgaleal hematomas can drain a significant amount of blood from the newborn. The blood loss puts the baby at risk of injuries including neonatal encephalopathy (brain damage), seizures, or even death. Research reports the reported mortality rate in infants with subgaleal hematoma is 22.8%.

Medical professionals must promptly identify and treat neonatal subgaleal hematomas to avoid or limit damage to the baby. 

Subgaleal hemorrhages are caused by trauma to the head during labor and delivery. The trauma severs veins between the scalp and the baby’s sinuses on the skull. Most commonly, this type of brain bleed 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. Vacuum extractors can cause head trauma when the physician uses the equipment improperly. Potentially harmful usage includes placing the suction cup on the wrong part of the baby’s head, applying too much pressure or force, keeping the cup suctioned for an extended period of time, or making too many attempts at using the vacuum extractor. When vacuum extractors or other assistive tools like forceps are used improperly, they can cause the baby to bleed within the subgaleal space (between the scalp and the skull).

Modern practices discourage risky vacuum- and forceps-assisted deliveries.

Certain factors present during pregnancy may make a baby more susceptible to subgaleal hemorrhaging. Doctors must consider these risk factors when making decisions about the pregnancy, labor, and delivery. Some of the most prominent risk factors for subgaleal hematoma in newborns include:

• First-time pregnancy (Primiparity)
• Male sex
• Prolonged second stage of labor
• Premature birth
• Cephalopelvic disproportion (CPD)
• Macrosomia

Subgaleal bleeding poses a serious threat of blood loss for infants. Doctors must closely monitor and quickly identify this bleed. When treating infants who underwent a difficult or assisted delivery, physicians should:

• 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

Infants suffering from a subgaleal hemorrhage may present with the following attributes:

• Palpable swelling on the head, which may shift with movement and expand over time due to additional bleeding.
• Tachycardia
• Pallor
• Decreasing blood pressure
• Diminished tone
• Respiratory distress

Newborns who underwent difficult vacuum extraction or forceps delivery should be treated with a minimum of 8 hours of observation. Medical staff should observe these newborns regardless of need for resuscitation or Apgar score. Th baby’s vital signs should also be assessed hourly. Head examinations should be done hourly if there is a concern about head swelling. These actions will help with early detection and diagnosis of hemorrhage.

Newborns diagnosed with subgaleal hematomas must receive treatment immediately in order to prevent any further damage.

Treatment for a subgaleal hematoma focuses on 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. During volume resuscitation, the infant receives liquids 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. Additionally, physicians should administer blood studies to ensure that the newborn is not suffering from any type of coagulopathy , or bleeding disorder. Coagulopathies may be present alongside subgaleal bleeding. If coagulopathy is present, medical staff must treat it according to the specific protocol.

An untreated subgaleal hematoma can lead to long-term negative outcomes, which can include:

• Neonatal encephalopathy
• Seizures
• Brain damage
• Hypoxic-ischemic encephalopathy (HIE)
• Periventricular leukomalacia
• Cerebral palsy
• Developmental disabilities
• Kernicterus (brain damage from mismanaged bilirubin issues/jaundice)

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.

A neonatal subgaleal hematoma can lead to long term health problems for your child. A brain bleeds can lead to extended time in the neonatal intensive care unit (NICU). If physicians fail to treat a subgaleal hemorrhage properly, it can be considered medical negligence. 

A birth injury lawsuit can help cover medical costs and ensure negligent medical staff are held accountable for their actions. If you have any questions about your legal options or whether your child’s treatment constituted medical malpractice, call the birth injury lawyers at ABC Law Centers. Our team is available 24/7 to hear your story and answer any questions you may have.