Bleeding into the soft tissues of the head is a common problem associated with birth and usually does not require intervention. These include:

  • A caput succedaneum is localized serosanguineous edema of the scalp that occurs between the skin and aponeurosis of the scalp. These swellings can cross suture lines and are usually due to pressure from the pelvis, uterus or vagina.
  • subgaleal or aponeuneuroic hematoma occurs between the aponeurosis of the scalp and the periosteum of the bone. The galea aponeurotica occurs from the occiput to the eyebrows and laterally to the temporalis fascia. It therefore can cross suture lines and is a large potential space where hemorrhage can occur.
    Subgaleal hematomas usually occur due to shearing of emissary veins between the intracranial venous sinus and the scalp.

  • A cephalohematoma is due to bleeding beneath the periosteum of the bone, i.e. between the periosteum and cortical bone. Therefore these swellings occur only over bone and do not cross suture lines. They occur in 2.5% of births.

Subgaleal hematomas are the least common and can occur along with caputs and cephalohematomas and therefore it is important to be aware of this diagnosis.
Caputs have localized skin edema. Subgaleal hematomas may be ballotable and have a fluid wave. As noted previously, a cephalohematoma does not cross suture lines, whereas the other two may.

Learning Point
Subgaleal hematomas are more common after assisted deliveries such as forceps and vacuum.
Moderate to severe subgaleal hematomas occur in 30/10,000 live births.
Of those cases, progressive anemia leading to hypovolemic shock and death occurs in 12-25% of cases.
Blood loss can be life threatening and even modest bleeding can cause exaggerated hyperbilirubinemia necessitating phototherapy and even exchange transfusion.
It is estimated that ~260 ml of blood increases the head circumference by 1 cm.

Intracranial hemorrhages are also more frequently associated with subgaleal hematomas (~50% in one study) and therefore seizures are also a possible complication.
Secondary infection of the hematoma is also an very uncommon complication.

Treatment includes treating the underlying hemorrhage with blood volume replacement, and treatment of congenital or acquired coagulopathies if present. Careful monitoring of the clinical condition and vital signs is necessary. Physical compression of the head may be helpful.