Presentation - Children`s Memorial Hermann Hospital

A Heads Up on Subgaleal
Hemorrhage
Cheryl McDuffie MSN, FNP-C, RNC-NIC
Disclosures
• I have nothing to disclose
Objectives
• After this presentation the learners will be
able to:
o Differentiate between common scalp swellings and
subgaleal hemorrhage
o Identify delivery history and physical assessment findings
which warrant frequent reassessment for signs of subgaleal
hemorrhage
The Case
• This is a published case presentation.
• Any resemblance to a case in any local
hospital is purely coincidental.
• All pictures are publicly available on the
internet. All patient pictures are from
published articles in reference list.
Case of Baby Jane
Assessment
41 week, 3891Gm female
Gravida-1 Para-0
Spontaneous labor
Vacuum extraction vaginal delivery
Tight nuchal cord cut approximately 50
seconds prior to delivery
• Mild shoulder dystocia
• Apgars 3 @ 1, 4 @ 5, and 7 @ 10 minutes
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Scalp
http://www.studyblue.com/notes/note/n/exam‐3/deck/6048127
Scalp swellings Scalp swellings
• Caput succedaneum
o Serosanguineous fluid in subcutaneous
tissues of presenting part
o Soft spongy, crosses suture lines, shifts with
positioning
o Minimal blood loss
o Resolves in 48-72 hours
Caput succedaneum
Scalp swellings
• Cephalohematoma
o Blood accumulation between skull bone
and periosteum
o Does not cross suture lines, initially firm
o Location- parietal and occipital bones,
85% unilateral
o Blood loss is rarely severe
o Resolves in 2 weeks to 3 months
Cephalohematoma
http://newborns.stanford.edu/PhotoGallery/Cephalohemato
ma1.html
Scalp swellings
• Subgaleal hemorrhage
o Rupture of the emissary veins, blood accumulation in the
subaponeurotic space.
o Massive blood loss possible, no barrier to stop the bleeding.
o Space can hold 240ml
• Newborn blood volume 78-86ml/Kg (Harriet Lane, 2012)
• 3Kg infant, 80ml/Kg = 240ml
o Space extends from nape of neck to orbits of the eyes and
from ear to ear.
o May see fluid wave
o Displace ear anteriorly
o Swelling around the eyes
o Resolves in 2-3 weeks High morbidity
http://www.studyblue.com/notes/note/n/11‐27‐12‐3pm‐scalp‐‐cranial‐
cavity/deck/4588068
http://www.oganatomy.org/projanat/neuroanat/3/eight.htm
Subgaleal hemorrhage
http://newborns.stanford.edu/PhotoGallery/Subgaleal3.html
http://www.ped.si.mahidol.ac.th/e‐diary/makehtml/division/thrathip/birthinjury/birth1.html
How I think about things…..
Caput Cephalohematoma
Subgaleal hemorrhage
Incidence • 1 in 2500 spontaneous vaginal births
• 10 fold increase with the use of forceps or vacuum
• Vacuum use is reported in approximately 49% of all
subgaleal hemorrhage
(Schierholz, E., Walker, S.R., 2010)
Vacuum Assisted Delivery
http://www.aafp.org/afp/2008/1015/p953.html
http://www.kentecmedical.com/manufacturer_detail.phtml?mfg_id=140&pline_id=155
&src=cat
http://www.utahmed.com/vacuumdelivery.htm
http://news.thomasnet.com/fullstory/Vacuum‐Assisted‐Delivery‐System‐is‐secure‐and‐gentle‐20004131
http://en.wikipedia.org/wiki/Ventouse
http://ispub.com/IJPN/5/2/7678
Risk factors associated with SGH after vacuum‐ assisted delivery
Nulliparous mother
Failed vacuum extraction
Inadvertent cup release (pop-offs)
Sequential use of vacuum and forceps
Apgar less than 8 @ 5 min following vacuum
assisted delivery
• Deflexing cup application (cup edge less than
3 cm from anterior fontanel)
• Paramedian cup application (cup centered
more than 1 cm lateral to sagittal suture)
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(Karlsen, 2013)
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/dec16_6(suppl1)/Pages/07.aspx
What do we place on all newborns?
Case of Baby Jane
Assessment
41 week, 3891Gm female
Gravida-1 Para-0
Spontaneous labor
Vacuum extraction vaginal delivery
Tight nuchal cord cut approximately 50
seconds prior to delivery
• Mild shoulder distocia
• Apgars 3 @ 1, 4 @ 5, and 7 @ 10 minutes
•
•
•
•
•
What else would you like to know?
• Question 1
• Question 2
• Question 3
How long?
• How long was the vacuum in place prior to
delivery?
o Time from initiation of vacuum to delivery 21
minutes
How many?
• How many pop-offs?
o “multiple pop-offs”
Where was the cup placed?
• Where is the chignon (cup mark)?
o Unknown
Case of Baby Jane
Assessment
41 week, 3891Gm female
Gravida-1 Para-0
Spontaneous labor
Vacuum extraction vaginal delivery
Tight nuchal cord cut approximately 50
seconds prior to delivery
• Mild shoulder distocia
• Apgars 3 @ 1, 4 @ 5, and 7 @ 10 minutes
•
•
•
•
•
Case of Baby Jane
•
•
•
•
•
Baby required bag mask ventilation for ~ 4 minutes
On examination “bogginess” of scalp noted
Baby described as flaccid and “shocked” looking
To nursery for observation
1.5 hrs of life transport called because baby paler
and unresponsive
Case of Baby Jane
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•
•
•
Fluid boluses suggested but no IV access
Transport noted severe swelling of the baby’s scalp
Hct @ 3.5 hrs of life 34 compared to cord Hct 49
Rec’d 50ml/Kg crystalloid and blood plus glucose,
NaHCO3, Dopamine
Case of Baby Jane
• Despite NICU care baby continued to deteriorate
with severe encephalopathy, profound
hypotension, renal failure, disseminated
intravascular coagulation (DIC), she died at 18
hours of life.
• Postmortem exam confirmed massive subgaleal
hemorrhage, with several diastatic fractures and
anoxic- ischemic changes within the brain.
Assessment
Get complete delivery history
Number of pop-offs, length of time with suction
Assess location of suction mark
Initial Head circumference
Reassessment of FOC- each cm increase in FOC =
approximately 40ml of blood loss (Reid, 2007)
• Assess for signs of shock- increased HR, decreased
BP, increased cap refill, pallor
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Plan
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Diagnostic testing
Blood gas, Hct, clotting studies,
Blood products- Hypovolemic shock
Blood volume replacement (FFP, PRBC)
Platelets and clotting factors (DIC)
Inotropes to maintain adequate blood pressure
Implementation
Nursing care
• Assess and stabilize respiratory status
• Assess head and skull for abrasions, ecchymosis,
and swelling
• Measure head circumference
• Obtain laboratory studies: blood gas, type and
cross, CBC, coagulation studies
• Obtain IV access; peripheral vs umbilical
• Communicate with family, transport team, and
physicians
Evaluation
• Continued frequent assessment of vital signs,
respiratory status, head examination and laboratory
studies
Did I meet the objectives?
• After this presentation the learners will be
able to:
o Differentiate between common scalp
swellings and subgaleal hemorrhage
o Identify delivery history and physical
assessment findings which warrant
frequent reassessment for signs of
subgaleal hemorrhage
References
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Chang, H., Peng, C., Kao, H., Hsu, C., Hung, H., Chang, J. Neonatal subgaleal hemorrhage: Clinical
presentation, treatment, and predictors of poor prognosis. Pediatrics International. 49. 903-907.
Davis, D. J. (2001) Neonatal subgaleal hemorrhage: diagnosis and management. Canadian Medical
Association Journal. 164(10). 1452-1453.
Federal Drug Administration (1998) FDA public health advisory: Need for caution when using vacuum
assisted delivery devices. Retrieved on July 8, 2013 from
http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/ucm062295.ht
m.
Karlsen, K, (2013) The STABLE Program Learner Manual. S.T.A.B.L.E Inc. Salt Lake City, UT.
O’Grady, J.P. (2012) Vacuum extraction. Medscape. Retrieved September 18, 2013 from
http://emedicine.medscape.com/article/271175-overview.
Reid, J. (2007) Neonatal subgaleal hemorrhage. Neonatal Network. 26(4). 219-227.
Schierholz, E., Walker, S.R. (2010) Responding to traumatic birth subgaleal hemorrhage, assessment and
management during transport. Advances in Neonatal Care. 10(6). 311-315.
Tscudy, M.M., Arcara, K.M. (2012) The Harriet Lane Handbook. 19th edition. Elsevier Philadelphia, PA.
Wetzel, E.A., Kingman, P.S. (2012) Subgaleal hemorrhage in a neonate with factor X deficiency following
a non-traumatic cesarean section. Journal of Perinatology. 32. 304-305.