Neonatal subgaleal hemorrhage in a multihospital healthcare system:
prevalence, associations, and outcomes
RD Christensen1,2, VL Baer1,2, and E Henry1,3
1
Women and Newborns Clinical Program, Intermountain Healthcare, Salt Lake City, UT,
Division of Neonatology and 3The Institute for Healthcare Delivery Research, Salt Lake City,
UT, USA.
2
Address correspondence to Robert D. Christensen, MD; Intermountain Healthcare, 4401
Harrison Blvd, Ogden, UT 84403, FAX 801-387-4316; Phone, 801-387-4300; E-mail,
rdchris4@ihc.com
RUNNING TITLE: Neonatal Subgaleal Hemorrhage
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships
relevant to this article to disclose.
ABSTRACT
Objective: Neonatal subgaleal hemorrhage is more common after operative delivery (vacuum or
forceps) than after non-instrumented delivery, but can occur when neither vacuum nor forceps
were used. We sought to describe recent vacuum and forceps usage in a multihospital system and
to identify all cases of subgaleal hemorrhage and to associate these with delivery type.
Methods: Using data repositories of Intermountain Healthcare we tabulated vacuum and forceps
use during the past 8½ years, seeking trends over time and as a function of the size of the
delivery service. Records were reviewed of all neonates where subgaleal hemorrhage was
recognized, seeking associations with delivery practices, and describing the outcomes.
Results: Vacuum-assisted deliveries constituted a higher proportion of deliveries in hospitals
with fewer than 1000 births per year, but forceps use was not associated with delivery service
size. Vacuum assistance occurred in 4.8% of all deliveries in the system, with no yearly change
in usage, but forceps use diminished from 5.3% of deliveries in 2002 to 4.7% in 2003 and to
2.4% thereafter. During this period 38 neonates were recognized to have a subgaleal hemorrhage.
Twenty-one occurred after vacuum, two after forceps, four after vacuum followed by forceps,
and 11 when neither vacuum nor forceps were used. Thirty-five were admitted to an intensive
care unit. Transfusions were given to 13, but no transfusions were given in the group where
neither vacuum nor forceps was used, suggesting their hemorrhages were less severe. Adverse
outcomes of subgaleal hemorrhage included death in two, persistent seizures in one, and
neurodevelopmental delay in another. All others where follow-up data were available (n=23)
were normal. In this health system the prevalence of recognized subgaleal hemorrhage is one
case per 7123 deliveries, one per 598 vacuum-assisted deliveries, and one per 1059 forcepsassisted deliveries.
Conclusion: In our system, severe subgaleal hemorrhage is invariably associated with the use of
vacuum or forceps. It is uncertain whether the poor outcome seen in 10% of our neonates with
subgaleal hemorrhage is due to the hemorrhage itself, or is the consequence of events preceding
or unrelated to the bleeding. We suggest that is it a wise practice, when vacuum or forceps are
December 1, 2010
Page 1
used, to convey this information to the pediatrician. We also suggest that the topic of subgaleal
hemorrhage be periodically reviewed, as continuing education for all involved in neonatal care.
INTRODUCTION
Hemorrhage into the subgaleal space can be a life-threatening neonatal complication
(1,2). However, the spectrum of severity ranges widely, from a small asymptomatic hemorrhage
to a massive one causing hypovolemic shock. Associations are well known between vacuum or
forceps-assisted delivery and subgaleal hemorrhage, but some cases occur when neither vacuum
nor forceps were applied (3-5).
Ali and Norwitz recently estimated that five to ten percent of vaginal deliveries in the
United States utilize either vacuum or forceps (6). An ACOG Practice Bulletin suggested that
subgaleal hemorrhages are detected in two to five percent of these operative vaginal deliveries
(7). Most published reports of neonatal subgaleal hemorrhage are from an individual hospital, or
are cases reported to the Centers for Disease Control (8,9). Neither source of information is ideal
for estimating the prevalence of neonatal subgaleal hemorrhage, or in assigning the risk of such
hemorrhage when vacuum or forceps are used.
Intermountain Healthcare is a multihospital healthcare system in Utah and Idaho. Using
the data repositories of this system we determined vacuum and forceps usage, analyzing trends in
usage over the recent past, and examining use as a function of the size of the delivery service.
We simultaneously reviewed the records of all neonates in the system where a subgaleal
hemorrhage was identified, and correlated the obstetrical and neonatal findings with outcomes.
METHODS
We conducted a cross-sectional, multihospital, retrospective data analysis of individuals
with dates of birth from January 1, 2002 through July 31, 2010 in the Intermountain Healthcare
databases. Intermountain Healthcare is a not-for-profit organization that, during the period of
study, owned and managed 21 hospitals with labor and delivery services in the Intermountain
West of the USA. In October 2003 an ICD-9 code for neonatal subgaleal hemorrhage was
introduced at Intermountain Healthcare. Medical records were reviewed for every neonate where
this code was applied between October 1, 2003 and July 31, 2010.
All diagnoses were ascertained from electronic data marts; Case Mix (the billing, coding,
and financial data mart used by Intermountain Healthcare), EVOX (the extended VermontOxford database), Storkbytes (the labor and delivery database), and ICD-9. The EMR is a
modified subsystem of Clinical Workstation. The 3M Company (Minneapolis, MN, USA)
approved the structure and definitions of all data points for use within the EMR program and
data were managed and accessed by authorized data analysts only. Fisher exact was used for
statistical analysis. P <0.05 was considered statistically significant. The study was approved by
the Institutional Review Board of Intermountain Healthcare as a retrospective deidentified
analysis not requiring individual consent.
RESULTS
In the 8½ year period studied, 261,921 live births were recorded at 21 hospitals. As
shown in table 1, hospitals delivering <1000/year utilized vacuum-assistance in a larger
December 1, 2010
Page 2
proportion of deliveries than did hospitals with more deliveries. In contrast, forceps use was not
associated with the size of the delivery service. Vacuum-assisted vaginal deliveries constituted
4.8% of all deliveries during the entire period, with no change from year to year. In contrast,
forceps-assistance diminished from 5.3% of deliveries in 2002 to 4.7% in 2003 and to 2.4%
thereafter for the remainder of the period studied. A small number of caesarean section
deliveries involved vacuum-assistance to withdraw the fetus from the hysterotomy. This
constituted less than 1% of the vacuum use and these cases are not included in the table.
Table 1. Vacuum-assisted and forceps-assisted vaginal deliveries at Intermountain Healthcare
Hospitals in the 8½ year period January 2002 through July 31, 2010.
Hospitals grouped
according to number
of live births/year*
>3000/year
1000-2999/year
100-999/year
<100/year
TOTAL
N
5
5
7
4
21
Live births
during the
period of study
136,505
107,827
16,476
1,113
261,921
Vacuum-assisted
vaginal
deliveries
5866 (4.3%)
4909 (4.5%)
1734 (11.0%)**
65 (5.8%)**
12,574 (4.8%)
Forceps-assisted
vaginal
deliveries
4563 (3.3%)
2968 (2.8%)
127 (0.7%)
42 (3.8%)
7700 (2.9%)
Hospitals were grouped based on deliveries/year in 2009. N= number of hospitals in this
grouping
*The largest of the current obstetrical services (Intermountain Medical Center) opened in
October 2007. One hospital closed the obstetrical service in 2003 and another did so in 2007.
**P<0.001 vs. hospital delivering ≥1000/year
Of the 261,921 live births 15,204 (5.8%) were admitted to a NICU (Table 2). NICU
admission was not more likely after vacuum-assisted delivery (4.0% of all vacuum deliveries
were admitted to a NICU) or forceps-assisted delivery (4.8% of forceps deliveries were admitted
to a NICU).
December 1, 2010
Page 3
Table 2. NICU admissions following all attempted (successful or failed) vacuum or forceps
delivery.
Hospitals grouped
according to number
of deliveries/year*
>3000/year
1000-2999/year
100-999/year
<100/year
TOTAL
NICU admissions
following any
delivery
9892 (7.2%)
4900 (4.5%)
336 (2.0%)
76 (6.8%)
15,204 (5.8%)
NICU admissions
following vacuumassisted delivery
396 (6.8%)
100 (2.0%)
11 (0.6%)
2 (3.0%)
509 (4.0%)
NICU admissions
following forcepsassisted delivery
265 (5.8%)
104 (3.5%)
1 (0.8%)
1 (2.3%)
371 (4.8%)
*The largest of the current obstetrical services (Intermountain Medical Center) opened in
October 2007. One hospital closed the obstetrical service in 2003 and another did so in 2007.
During the period studied 38 neonates were recognized to have a subgaleal hemorrhage.
Thirty of these were born at an Intermountain Healthcare hospital and eight were born at other
hospitals and transported into an Intermountain Healthcare hospital. No neonate with a subgaleal
hemorrhage was born in an Intermountain Healthcare hospital and transported to a nonIntermountain Healthcare hospital. Since the ICD-9 code for subgaleal hemorrhage was
instituted in October 2003, 213,706 births were recorded in this system, of which 30 had the
diagnosis of subgaleal hemorrhage. On this basis, the prevalence estimate is one case per 7124
births. Of 11,365 vacuum-assisted deliveries during this period 19 had the diagnosis of subgaleal
hemorrhage. Thus the prevalence estimate is one case per 598 vacuum-assisted births. Of 5294
forceps-assisted deliveries five had the diagnosis of subgaleal hemorrhage, with a prevalence
estimate of one case per 1059 forceps-assisted births.
As shown in table 3, three or four cases of subgaleal hemorrhage were recognized each
year from 2004 through 2007, with eight cases in 2008, eight in 2009, and six in the first six
months of 2010. Birth weights of affected neonates were 3482±625 grams (mean±SD),
gestational age was 38±2 weeks and 68% were male. Twenty-one of the 38 cases of subgaleal
hemorrhage occurred after vacuum-assistance, two after forceps, and four after vacuum followed
by forceps. Eleven cases occurred when neither vacuum nor forceps were used; eight of these
were vaginal deliveries and three were caesarean.
December 1, 2010
Page 4
Table 3. Features of 38 neonates with a subgaleal hemorrhage.
g, grams; w, weeks; vag, vaginal; fcp, forceps; Csec, cesarean section; ICU, admitted to an
Birth
Year
Birth
weight
(g)
Gest
Age
(w)
Delivery
Mode
2003
2004
2004
2004
2004
2005
2005
2005
2005
2006
2006
2006
2007
2007
2007
2007
2008
2008
2008
2008
2008
2008
2008
2008
2009
2009
2009
2009
2009
2009
2009
2009
2010
2010
2010
2010
2010
2010
3627
3012
3375
3102
3385
4621
2389
4097
2580
3125
3770
3449
3200
3468
3650
3279
2373
3605
3215
2779
4233
4005
3510
3175
4895
2572
2940
4145
4430
4905
3685
3754
3616
3455
3435
2807
3600
3063
37
40
40
35
39
40
34
39
37
35
38
41
37
38
41
39
33
39
39
34
40
40
38
35
39
34
37
41
40
40
37
39
38
40
40
37
39
39
Vag/Vac
Vag/Vac
Vag/Vac/Fcp
Vag/Vac
Vag
Vag
Csec
Vag/Vac
Vag/Vac
Vag/Vac
Csec
Vag/Vac
Vac/Csec
Vac/Fcp/Csec
Vag/Fcp
Vag/Fcp
Vag
Vag/Vac
Vac/Fcp/Csec
Vag/Vac
Vag/Vac
Vag
Vag/Vac
Vag/Vac
Vag/Vac
Vag
Vag/Vac
Vag/Vac/Fcp
Vag/Vac /Csec
Vag
Csec
Vag/Vac
Vag/Vac/Csec
Vag/Vac
Vag/Vac
Vag
Vag
Vag/Vac
Apgar
score
@5
min
8
4
4
7
7
7
9
9
5
9
8
4
6
5
8
4
8
8
9
8
9
8
7
9
9
5
9
5
9
9
8
9
8
8
8
4
9
8
Age at
diag (h)
ICU
(Y vs. N)
3
Birth
Birth
Birth
Birth
Birth
Birth
4
Birth
Birth
1
Birth
8
Birth
Birth
Birth
Birth
Birth
Birth
Birth
Birth
Birth
Birth
Birth
7
8
5
Birth
Birth
Birth
Birth
Birth
1
2
Birth
Birth
Birth
Birth
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Diagnosis
confirmed
by imaging
(Y vs. N)
N
Y
Y
N
Y
Y
Y
Y
Y
Y
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
Y
Y
Y
Y
Y
N
Y
Y
N
Y
Y
Y
RBC
trans
given
(N)
0
1
0
1
0
0
0
1
2
0
0
2
2
2
0
3
0
0
1
0
0
0
0
1
0
0
0
0
1
0
0
0
1
0
0
0
0
1
LOS
(d)
Outcome
12
7
2
2
4
3
10
43
72
14
6
10
17
9
4
4
18
3
8
6
7
2
4
12
2
13
7
4
7
6
6
4
6
7
7
19
23
11
Norm
Norm
Norm
Expired
Norm
NA
NA
Norm
NA
Norm
Norm
NA
NA
NA
Norm
Expired
Norm
Norm
Norm
Seizures
NA
NA
Norm
Norm
Norm
Norm
Norm
Norm
NA
NA
Norm
Norm
Norm
Norm
Norm
*
Norm
NA
intensive care unit; diag, diagnosis; h, hours; d, days; LOS, length of hospital stay
*Multiple problems related to hypoxic ischemic encephalopathy
December 1, 2010
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Five minute Apgar scores in the 38 neonates ranged from 4 to 9. Most cases (29/38) were
recognized to have a subgaleal hemorrhage at the time of birth; four were not recognized at
delivery but were seen during the first three hours, and five were not recognized until four to
eight hours after birth. Thirty-five of the 38 neonates were admitted to an intensive care unit; 34
to a NICU and one a cardiac intensive care unit. The other three were cared for in a well baby
nursery.
One or more erythrocyte transfusions were administered to 13 of the 38. None who
developed a subgaleal hemorrhage where neither vacuum nor forceps were used (n=11) received
a transfusion, compared with 13 of the 27 where vacuum or forceps were used (P=0.013). About
half of those with a subgaleal hemorrhage following vacuum received a transfusion (10 of 21),
which is the same proportion of those transfused after forceps (1 of 2) and where both vacuum
and forceps were used (2 of 4). None of the 38 received recombinant Factor VIIa and none were
treated with head wrapping.
Twenty-nine had an imaging study to confirm the diagnosis of subgaleal hemorrhage.
The length of hospital stay ranged from two to 72 days. Those with a stay exceeding 20 days
included one with myotonic dystrophy, one with hypoplastic left heart, and one with significant
feeding problems who was discharged home with a feeding tube. Adverse outcomes of the
affected patients included death in two, a persistent seizure disorder in one, and significant
neurodevelopmental delay in another. The two who died had refractory hypotension and
acidosis, and both received a transfusion. One died on day 2 (35 wk gestation after vacuumassisted vaginal delivery) and the other died on day 4 (39 wk gestation after forceps-assisted
vaginal delivery). The two survivors with a subgaleal hemorrhage who are known to have a poor
neurodevelopmental outcome did not receive a transfusion (a 34 week gestation after vacuumassisted vaginal delivery and a 37 wk gestation after vaginal delivery). Of the remaining 34
neonates, 23 had follow-up in an Intermountain Healthcare facility all were judged to be normal.
Eleven had follow-up in an outside facility and their outcomes are unknown to us.
DISCUSSION
Using the data repositories of a multihospital healthcare system, we described patterns of
vacuum-assisted and forceps-assisted deliveries over a recent 8½ year period. Because of the
association between operative delivery and subgaleal hemorrhage, we used the same data-sets to
locate all instances where a neonatal subgaleal hemorrhage was identified.
The pathogenesis of neonatal subgaleal hemorrhage involves trauma to the scalp. The
subgaleal space is a potential space, meaning two adjacent tissues, not tightly adjoined, can be
separated to create a previously non-existent cavity. The two tissues bordering the subgaleal
space are the periosteum of the skull and the flat broad tendinous material covering the cranium
called the galea aponeurotica (also known as the epicranial aponeurosis or the aponeurosis
epicranialis). The subgaleal space can fill with blood following rupture of veins that connect
scalp veins to the dural sinus. Veins traversing this potential space, termed emissary veins, can
rupture after twisting, sheering, or torsion of the scalp. McQuivey suggested that the subgaleal
space of a neonate can accommodate 50 to 80% of the blood volume (10), and consequently
massive bleeding can occur into this space, resulting in hypovolemic shock.
December 1, 2010
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A subgaleal hemorrhage can be noted at birth, or can appear gradually over the first hours
(11,12). Such was the case in this series where most were evident at birth but some were not
recognized for up to eight hours. The diagnosis is clinical in many cases, with an enlarging head
due to swelling which crosses suture lines, ending at the orbits anteriorly and at the nape of the
neck posteriorly, and accompanied by clinical and laboratory evidence of diminishing circulating
blood volume.
Chang et al recently reported the prevalence of subgaleal hemorrhage in Taiwan to be
one case per 1667 deliveries and one case per 218 vacuum-assisted deliveries (13). This was
based on the period January 1995 to December 2004. We found a lower prevalence; specifically
we found one case per 7124 deliveries, one per 598 vacuum-assisted deliveries, and one per 1059
forceps-assisted deliveries. Although our study period is more current (2003 – 2010) our figures
might be underestimates on the basis that recognition of this complication is likely increasing in
our system. For instance, if we consider only the data from January 2008 our overall prevalence
is one case per 4707 deliveries. We speculate that the odds of a subgaleal hemorrhage is even
higher when multiple attempts at vacuum delivery have failed, but we were unable to calculate
this as our data does not include the number of vacuum applications. Moreover, the odds are
probably higher when vacuum and forceps fail to result in vaginal delivery and emergency
cesarean section is required. However, the relative rarity of this situation in our data prevents any
meaningful estimate of odds.
Management of neonatal subgaleal hemorrhage involves NICU monitoring and serial
quantification of the hemoglobin or hematocrit. In our series, over 1/3rd received RBC
transfusions. We speculate that transfusion recipients generally had the largest subgaleal blood
loss, although this cannot be determined using retrospective methods. Half of the neonates with a
subgaleal hemorrhage after vacuum or forceps received one or more transfusions. In contrast
none of those with a subgaleal hemorrhage when neither vacuum nor forceps were used had a
RBC transfusion. On this basis we speculate that the volume of blood loss into the subgaleal
space is generally larger when subgaleal hemorrhage follows use of a vacuum or forceps.
Another management option, pressure wrapping of the head, has been advocated by some but it
is not clear that this is helpful and might contribute to increased intracranial pressure (2,14).
Recombinant activated factor VII has been used in cases where hemorrhage would not stop using
plasma and platelet transfusion to correct coagulopathy and thrombocytopenia (15,16).
Coagulopathy should be considered, particularly when hypotension and acidosis accompany a
falling hemoglobin. Among severe cases renal failure should also be anticipated. Even in less
severe cases hyperbilirubinemia should be anticipated, and sometimes requires prolonged
phototherapy.
It seems to us that most neonates with a subgaleal hemorrhage have a good outcome, and
perhaps this is improving over time. For instance, the mortality rate in the Taiwan study was
12% and in ours was 5%. This is in contrast to earlier reports where mortality rates of 17 to 25%
were cited (17,18). Neurodevelopmental problems were present in 17% in the Taiwan report and
in 5% of our cases, but it is not clear whether the neurological damage is ascribable to the
hemorrhage itself, or is the result of events preceding or coexisting with the hemorrhage.
December 1, 2010
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Owing to the relative rarity of severe cases of subgaleal hemorrhage, many clinicians
have not managed neonates who have this problem. Although most cases seem to do well,
vigilance is needed to avoid morbidity and mortality. To foster anticipatory neonatal care for
these patients, we advocate that when vacuum or forceps are used, this information be conveyed
to the clinician who will provide the neonatal care. We also advocate continuing education for all
who participate in neonatal care, regarding diffuse neonatal swelling of the head, crossing suture
lines, prompting a consideration of subgaleal hemorrhage with subsequent institution of
appropriate monitoring and, where indicated, treatment strategies.
ACKNOWLEDGEMENT
The authors thank Heather Major, MD, Division of Maternal/Fetal Medicine, McKay-Dee
Hospital center, for valuable assistance with this study design.
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