Neonatal Subgaleal Hemorrhage



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Neonatal Subgaleal Hemorrhage

Transfer to Mother-Baby Unit

Surveillance after transfer back to MBU:

  • OK to breastfeed ad lib
  • Vital signs q4h until 48hr of life
  • Obtain CBC/diff and serum bilirubin at 24hr of life (time with newborn screen)
  • Obtain transcutanous bilirubinometry at any time if clinical concern for worsening jaundice
  • Head circumference q4h until 24hr of life, then q8h until 48hr of life
  • Continue assessing and documenting appearance of scalp along with infant's color and vital signs
  • Any physical exam, laboratory, or vital sign abnormalities (including mild tachycardia or tachypnea) could be early sign of shock and prompt transfer back to NICU - discuss with neonatologist.

Well-appearing x8hr?

Inclusion Criteria
  • Boggy or fluctuant scalp
  • Scalp with fluid wave on exam
  • Vacuum- or forceps-assisted delivery
  • Other significant concern for subgaleal hemorrhage
Exclusion Criteria
  • Scalp edema of other or unknown etiology
  • Unsure if subgaleal hemorrhage

Concern for clinical deterioration:

  • If concern for worsening exam or decreasing Hgb/Hct:
  • Contact neonatologist immediately
  • Start IVF (D10W)
  • Coagulation studies (PT/PTT/INR)
  • Blood gas
  • D-dimer
  • Consider CT scan or MRI of head (MRI is preferred)
  • Radiographs of skull may be useful to identify underlying skull fractures

  • Asymptomatic SGH
  • Pediatric hospitalist continues to manage care
  • Transfer to NICU for minimum 8 hours

Detailed Assessment

  • Obtain umbilical cord gases (venous, arterial) for all suspected SGH and instrument-assisted deliveries
  • Signs/symptoms of shock: tachypnea, tachycardia, hypotension, pallor/mottling, capillary refill ≥3 seconds
  • Neurologic abnormalities: hypotonia, decreased activity, lethargy
  • Decreasing Hgb/Hct
  • Increasing head circumference or head asymmetry
  • Scalp swelling extending ear-to-ear, from eyebrows to neck, and/or displaces ears inferiorly or anteriorly

  • Symptomatic SGH
  • Notify neonatologist on-call immediately
  • Consider transfer to NICU with higher level of care

NICU management of asymptomatic SGH

  • Place peripheral IV and draw labs:
  •     Blood glucose every hour if not started on IVF (and per NICU protocol)
  •     CBC/diff
  •         at 1hr, 4hr, and 24hr if stable
  • Give Vitamin K if not already given
  • NPO for first 2hr of monitoring (+/- IVF)
  • MD to perform physical exam assessments at admission, 1hr, 4hr, and 8hr of life with documentation of:
  •     Scalp appearance
  •     Infant's color and perfusion
  •     Sarnat assessment
  • RN to measure vital signs every 30min x2hr, every 1hr x3hr, then q4h until 48hr of life (and once prior to transfer out of NICU)
  • RN to document appearance of scalp along with infant's color and perfusion
  • Measure head circumference upon admission and every 1hr x4hr, then every 4hr x24hr, then every 8hr until 48hr of life
  • Start IVF if hypoglycemia or worsening exam
  • Check serum bilirubin at 24hr of life
  • If unstable discuss with neonatologist

Discuss with neonatologist