Risk factors associated with subgaleal hemorrhage in neonates exposed to vacuum extraction

The use of intrapartum ultrasound in operative vaginal birth: a retrospective cohort study

BACKGROUND

Poor outcomes from operative vaginal birth have been associated with failure to recognize malposition, breakdown in interdisciplinary communication, and deviation from accepted guidelines. We recently implemented a safety bundle including routine intrapartum ultrasound and a structured time-out and procedural checklist aiming to reduce maternal and perinatal morbidity from operative vaginal birth.

OBJECTIVE

This study aimed to compare births where intrapartum ultrasound was used and those where it was not used during a safety bundle implementation period at Monash Health.

STUDY DESIGN

We performed a retrospective cohort study at Monash Health during the transitional phase of implementing an operative vaginal birth safety bundle. We studied all women with operative vaginal birth and fully dilated cesarean delivery with a singleton cephalic term fetus. We compared births for which intrapartum ultrasound was used and those for which it was not. The primary outcome was neonates delivered in an unexpected position. Neonatal and maternal morbidity were also assessed, including a neonatal composite of Apgar score <7 at 5 minutes, cord lactate >8 mmol/L, need for resuscitation, significant birth trauma, or neonatal intensive care unit admission. To control for confounding by indication, we estimated propensity scores for the probability of using intrapartum ultrasound for each case based on maternal and labor characteristics, and adjusted the effect estimates for the propensity scores using multivariable logistic regression models.

RESULTS

From August 2022 to July 2023, there were 1205 operative vaginal births or fully dilated cesarean deliveries at Monash Health, including 743 (61.7%) forceps, 346 (28.7%) vacuum, and 116 (9.6%) fully dilated cesarean deliveries. Over this time, we observed increased uptake of intrapartum ultrasound from 26% in August 2022 to 60% (P<.001) in July 2023, of the time-out from 21% to 58% (P<.001), and the checklist from 33% to 80% (P<.001) of operative second-stage births. Among the births where intrapartum ultrasound was used (n=509), compared with those where it was not (n=696), there were significantly more forceps births (67% vs 58%; adjusted odds ratio, 1.35; 95% confidence interval, 1.05-1.74; P=.021) and a reduction in vacuum births (24% vs 32%; adjusted odds ratio, 0.77; 95% confidence interval, 0.58-1.01; P=.059). There were no significant differences in fully dilated cesarean delivery or maternal morbidity. Intrapartum ultrasound use was associated with significantly fewer infants being delivered in an unexpected position (0.2% vs 2.2%; adjusted odds ratio, 0.08; 95% confidence interval, 0.00-0.44; P=.019) and a significant reduction in composite neonatal morbidity (22% vs 25%; adjusted odds ratio, 0.73; 95% confidence interval, 0.54-0.97; P=.031).

CONCLUSION

During the implementation of a safety bundle, the use of ultrasound before operative vaginal birth was associated with fewer infants delivered in an unexpected position and reduced neonatal morbidity.

Precision of vacuum cup placement and its association with subgaleal hemorrhage and associated morbidity in term neonates

PURPOSE

To evaluate whether the precision of vacuum cup placement is associated with failed vacuum extraction(VE), neonatal subgaleal hemorrhage(SGH) and other VE-related birth trauma.

METHODS

All women with singleton term cephalic fetuses with attempted VE were recruited over a period of 30 months. Neonates were examined immediately after birth and the position of the chignon documented to decide whether the cup position was flexing median or suboptimal. Vigilant neonatal surveillance was performed to look for VE-related trauma, including subgaleal/subdural hemorrhages, skull fractures, scalp lacerations. CT scans of the brain were ordered liberally as clinically indicated.

RESULTS

The VE rate was 5.89% in the study period. There were 17(4.9%) failures among 345 attempted VEs. Thirty babies suffered from subgaleal/subdural hemorrhages, skull fractures, scalp lacerations or a combination of these, giving an incidence of VE-related birth trauma of 8.7%. Suboptimal cup positions occurred in 31.6%. Logistic regression analysis showed that failed VE was associated with a non-occipital anterior fetal head position (OR 3.5, 95% CI 1.22-10.2), suboptimal vacuum cup placement (OR 4.13, 95% CI 1.38-12.2) and a longer duration of traction (OR 8.79, 95% CI 2.13-36.2); while, VE-related birth trauma was associated with failed VE (OR 3.93, 95% CI 1.08-14.3) and more pulls (OR 4.07, 95% CI 1.98-8.36).

CONCLUSION

Suboptimal vacuum cup positions were related to failed VE but not to SGH and other vacuum-related birth trauma. While optimal flexed median cup positions should be most desirable mechanically to effect delivery, such a position does not guarantee prevention of SGH.

Head position and vacuum-assisted delivery using the Kiwi Omnicup

OBJECTIVE

To evaluate the association between fetal head position during prevacuum assessment and adverse outcomes.

METHOD

This retrospective cohort study included all vacuum-assisted deliveries using the Kiwi Omnicup over 5 years. Primary outcomes were third- or fourth-degree perineal tear, pH < 7.1, and subgaleal hematoma (SGH). AGAR, neonatal intensive care unit admission, cephalohematoma, Erb's palsy, third-stage duration, and postpartum hemorrhage were secondary. Outcomes were compared between the occiput posterior (OP) and occiput anterior (OA) positions.

RESULTS

The study included 1960 patients. OP position was more likely to involve epidural analgesia (311 [82.5%] vs. 1216 [77%], P = 0.020), higher fetal head station (P = 0.001), higher percentage of cup detachments (121 cases [32.1%] vs. 307 [19.4%], P = 0.001), and longer procedure (5.5 ± 3.7 min vs. 4.7 ± 2.8 min, P = 0.001). OP was associated with umbilical cord pH < 7.1 (21 [5.5%] vs. 52 [3.9%], P = 0.032), NICU admissions (16 [4.2%] vs. 38 [2.4%], P = 0.049), SGH (18 [4.8%] vs. 38 [2.4%], P = 0.013), and high-degree perineal tears (12 [3.2%] vs. 26 [1.7%], with borderline significance, P = 0.051). SGH and high-grade tears remained significantly associated with OP position (P = 0.008 and P = 0.016, respectively) after adjusting for maternal age, nulliparity, diabetes, epidural anesthesia, preprocedure head station, and birth weight.

CONCLUSION

OP position is an independent risk-factor for anal sphincter injury and SGH during vacuum-assisted delivery.

Head Injuries Related to Birth Trauma in Low Birthweight Neonates During Vacuum Extraction

Introduction Preterm delivery (gestational age < 34 w) is a relative contraindication to vacuum extraction. Current data do not differentiate clearly between preterm delivery and low birthweight. We aimed to evaluate the impact of non-metal vacuum cup extraction on neonatal head injuries related to birth trauma in newborns with low birthweights (< 2500 g). Materials and Methods A retrospective cohort of 3377 singleton pregnancies delivered by vacuum extraction from 2014 to 2019. All were gestational age ≥ 34 w. We compared 206 (6.1%) neonates with low birthweights < 2500 g to 3171 (93.9%) neonates with higher birthweights, divided into 3 subgroups (2500-2999 g, 3000-3499 g, and ≥ 3500 g). A primary composite outcome of neonatal head injuries related to birth trauma was defined. Results The lowest rates of subgaleal hematoma occurred in neonates < 2500 g (0.5%); the rate increased with every additional 500 g of neonatal birthweight (3.5%, 4.4% and 8.0% in the 2500-2999 g, 3000-3499 g, and ≥ 3500 g groups, respectively; p = 0.001). Fewer cephalohematomas occurred in low birthweight neonates (0.5% in < 2500 g), although the percentage increased with every additional 500 g of birthweight (2.6%, 3.3% and 3.7% in the 2500-2999 g, 3000-3499 g, and ≥ 3500 g groups, respectively, p = 0.020). Logistic regression found increasing birthweight to be a significant risk factor for head injuries during vacuum extraction, with adjusted odds ratios of 8.12, 10.88, and 13.5 for 2500-2999 g, 3000-3499 g, and ≥ 3500 g, respectively (p = 0.016). NICU hospitalization rates were highest for neonates weighing < 2500 g (10.2%) compared to the other groups (3.1%, 1.7% and 3.3% in 2500-2999 g, 3000-3499 g, ≥ 3500 respectively, p < 0.001). Conclusions Vacuum extraction of neonates weighing < 2500 g at 34 w and beyond seems to be a safe mode of delivery when indicated, with lower rates of head injury related to birth trauma, compared to neonates with higher birthweights.

Neonatal subgaleal hemorrhage: twenty years of trends in incidence, associations, and outcomes

BACKGROUND

In 2011, we reported 38 neonates with subgaleal hemorrhage (SH), relating an increasing incidence. It is unclear whether the incidence in our hospitals continued to rise and which risk factors and outcomes are associated with this condition.

DESIGN

We retrospectively analyzed every recognized case of SH in our hospitals from the end of our previous report (2010) to the present (2022). We redescribed the incidence, scored severity, tabulated blood products transfused, and recorded outcomes.

RESULTS

Across 141 months, 191 neonates were diagnosed with SH; 30 after vacuum or forceps. The incidence (one/1815 births) was higher than in our 2011 report (one/7124 births). Also, severe SH (requiring transfusion) was more common (one/10,033 births vs. one/20,950 births previously). Four died (all with severe SH) and 12 had neurodevelopmental impairment.

CONCLUSION

Recognized cases of SH are increasing in our system without a clear explanation. Adverse outcomes are rare but continue to occur.

Can We Predict Feto-Maternal Adverse Outcomes of Vacuum Extraction?

Introduction Vacuum extraction (VE) is an important modality in modern obstetrics, yet sometimes results in maternal or neonatal adverse outcomes, which can cause a lifetime disability. We aimed to characterize potential risk factors for adverse outcomes that in retrospect would have led the physician to avoid the procedure. Materials and Methods Retrospective cohort of 3331 singleton pregnancies, ≥ 34 w delivered by VE. 263 deliveries (7.9%) incurred a VE-related feto-maternal adverse outcome, defined as one or more of the following: 3-4th-degree perineal laceration, subgaleal hematoma, intracranial hemorrhage, shoulder dystocia, clavicular fracture, Erb's palsy or fracture of humerus. 3068 deliveries (92.1%) did not have VE-related adverse outcomes. Both groups were compared to determine potential risk factors for VE adverse outcomes. Results Multivariable regression found seven independent risk factors for VE-related feto-maternal adverse outcomes: Nulliparity - with an odds ratio (OR) of 1.82 (95% CI = 1.11-2.98, p = 0.018), epidural anesthesia (OR 1.99, CI = 1.42-2.80, p < 0.001), Ventouse-Mityvac (VM) cup (OR 1.86, CI = 1.35-2.54, p < 0.001), prolonged second stage as indication for VE (OR 1.54, CI = 1.11-2.15, p = 0.010), cup detachment (OR 1.66, CI = 1.18-2.34, p = 0.004), increasing procedure duration (OR 1.07 for every additional minute, CI = 1.03-1.11, p < 0.001) and increasing neonatal birthweight (OR 3.42 for every additional kg, CI = 2.33-5.02, p < 0.001). Occiput anterior (OA) position was a protective factor (OR 0.62, CI = 0.43-0.89, p = 0.010). Conclusions VE-related adverse outcomes can be correlated to clinical characteristics, such as nulliparity, epidural anesthesia, VM cup, prolonged second stage as indication for VE, cup detachment, prolonged procedure duration and increasing neonatal weight. OA position was a protective factor. This information may assist medical staff to make an informed decision whether to choose VE or cesarean delivery (CD).

Adverse outcomes in vacuum-assisted delivery after detachment of non-metal cup: a retrospective cohort study

PURPOSE

To evaluate neonatal and maternal outcomes associated with detachment of non-metal vacuum cup during delivery and to identify risk factors for these detachments.

METHODS

This retrospective cohort study included women with singleton pregnancy, who underwent vacuum-assisted vaginal delivery with a non-metal vacuum cup in a single academic institution, January 2014-August 2019. Failed vacuum deliveries were excluded. Primary outcomes were defined as subgaleal hematoma (SGH) and cord blood pH < 7.15. Secondary outcome included other neonatal complications and adverse maternal outcomes. Outcomes were compared between vacuum-assisted deliveries with and without cup detachment during the procedure.

RESULTS

A total of 3246 women had successful VAD and met the inclusion criteria. During the procedure, the cup detached at least once in 665 (20.5%) deliveries and did not detach in 2581 (79.5%). The cup detachment group experienced higher rates of SGH (8.9% vs. 3.5%, p = 0.001) and cord blood pH < 7.15 (9.8% vs. 7.1%, p = 0.03). There were also more neonatal intensive care unit admissions (NICU) (4.4% vs. 2.7%, p = 0.03) and more fetuses with occiput posterior position (70.8% vs. 79.4%, p = 0.001), the vacuum duration was slightly longer (6 ± 3.7 vs. 5 ± 2.9 min) and more neonates had birth weights > 3700 g (14.1% vs, 10.3%, p = 0.006). Interestingly, there were more males in that group (60.6 vs. 54.6, p = 0.005). All these factors remained significant after controlling for potential confounders.

CONCLUSIONS

Vacuum cup detachment has several predictive characteristics and is associated with adverse neonatal outcomes that should be incorporated into decisions made during the procedure.

Neonatal morbidity in a low volume forceps practice

BACKGROUND

Currently, the use of FE is decreasing and neonatal adverse outcomes following FE are underreported. We aimed to evaluate the rate of neonatal adverse outcomes in current obstetric practice at two university hospitals with a low FE volume.

METHODS

A multicentre retrospective study. All singleton pregnancies delivered by forceps extraction between 2011 and 2020 were analyzed. The characteristics of the deliveries with a composite neonatal adverse outcome (CNAO) were analyzed and compared with those without.

RESULTS

The study cohort included 861 neonates delivered by FE. The CNAO was recorded in 131 (15.2%). Women in the CNAO group gained less weight during pregnancy (mean 13 kg vs. 15 kg, p = .014). Factors found to be associated with CNAO were preterm delivery (gestational age < 37°^/7) (26 (19.8%) vs. 44 (6.0%), OR [95% CI]: 3.86 (2.28-6.52), p < .001), low birth weight (23 (17.6%) vs. 44 (6.0%), OR [95% CI] 3.32 (1.92-5.71), p < .001), and smaller head circumference (329 vs. 331 mm, OR [95% CI] 0.79 (0.67-0.93), p = .035). In a multivariate analysis, gestational age (adjusted OR [95% CI] 0.672 (0.546-0.826), p < .001) and maternal weight gain during pregnancy (adjusted OR [95% CI]: 0.950 (0.904-0.998), p = .042), were both negatively associated with CNAO. Among term deliveries, the only factor found to be independently associated with CNAO was maternal weight gain during pregnancy (adjusted OR [95% CI]: 0.951 (0.910-0.994), p = .025).

CONCLUSIONS

In the setting of low volume FE, this mode of delivery is associated with a relatively low rate of neonatal morbidity.

SYNOPSIS

Performance of forceps extraction in the setting of low volume practice is associated with a relatively low rate of neonatal morbidity.

[The Neonatal Subgaleal Hematoma - A Neonatal Emergency]

Subgaleal hematoma (SGH) is a rare complication in neonates that may lead to hemorrhagic shock due to significant blood loss into the subgaleal space. We report of two neonates who developed subgaleal hematoma with severe hemorrhagic shock and encephalopathy. In the first case of a mature female neonate, the development of the subgaleal hematoma was promoted by early-onset sepsis and delivery by vacuum extraction. The second case, of a male preterm neonate, was a complicated fetal development followed by secondary cesarean section. Both cases highlight that a subgaleal hematoma is a severe neonatal emergency. In addition to prompt treatment of the shock, therapy of the coagulopathy is essential.

Association between the number of pulls and adverse neonatal/maternal outcomes in vacuum-assisted delivery

OBJECTIVES

To determine the association between the number of pulls during vacuum-assisted deliver and neonatal and maternal complications.

METHODS

This was a single-center observational study using a cohort of pregnancies who underwent vacuum-assisted delivery from 2013 to 2020. We excluded pregnancies transitioning to cesarean section after a failed attempt at vacuum-assisted delivery. The number of pulls to deliver the neonate was categorized into 1, 2, 3, and ≥4 pulls. We used logistic regression models to investigate the association between the number of pulls and neonatal intensive care unit (NICU) admission and maternal composite outcome (severe perineal laceration, cervical laceration, transfusion, and postpartum hemorrhage ≥500 mL).

RESULTS

We extracted 480 vacuum-assisted deliveries among 7,321 vaginal deliveries. The proportion of pregnancies receiving 1, 2, 3, or ≥4 pulls were 51.9, 28.3, 10.8, and 9.0%, respectively. The crude prevalence of NICU admission with 1, 2, 3, and ≥4 pulls were 10.8, 16.2, 15.4, and 27.9%, respectively. The prevalence of NICU admission, amount of postpartum hemorrhage, and postpartum hemorrhage ≥500 mL were significantly different between the four groups. Multivariable logistic regression analysis found the prevalence of NICU admission in the ≥4 pulls group was significantly higher compared with the 1 pull group (adjusted odds ratio, 3.3; 95% confidence interval, 1.4-7.8). In contrast, maternal complications were not significantly associated with the number of pulls.

CONCLUSIONS

Vacuum-assisted delivery with four or more pulls was significantly associated with an increased risk of NICU admission. However, the number of pulls was not associated with maternal complications.

Second stage expedite delivery of low birth weight neonates: Emergent cesarean delivery versus vacuum assisted delivery

OBJECTIVE

To determine maternal and neonatal outcomes among women undergoing second stage emergent cesarean delivery (ECD) versus vacuum-assisted delivery (VAD) of low birthweight neonates.

MATERIALS AND METHODS

A retrospective cohort study from two tertiary medical centers. We included women who underwent either ECD or VAD during the second stage of labor, and delivered neonates with a birthweight of <2500 g during 2011-2019. Characteristics and outcomes were compared between the groups. The primary outcome was the rate of a composite adverse neonatal outcome, defined as the presence of ≥1 of the following: Apgar 5 min < 7, respiratory distress syndrome, neonatal intensive care unit admission, mechanical ventilation and intrapartum fetal death.

RESULTS

The study cohort included 611 patients, of whom 46 had ECD and 565 had VAD. Baseline characteristics did not differ between the groups. The rate of Apgar score < 7 at 1 min was higher among the ECD group]10 (22%) vs. 29 (5%), OR (95% CI) 5.1 (2.3-11.3), p < 0.001[. Other neonatal and maternal outcomes were similar in both groups.

CONCLUSIONS

Neonatal and maternal outcomes do not differ substantially between ECD and VAD of neonates weighing <2500 g. This information may be useful when contemplating the preferred mode of delivery in this setting.

Perinatal outcome after vacuum assisted delivery with digital feedback on traction force; a randomised controlled study

Background

Low and mid station vacuum assisted deliveries (VAD) are delicate manual procedures that entail a high degree of subjectivity from the operator and are associated with adverse neonatal outcome. Little has been done to improve the procedure, including the technical development, traction force and the possibility of objective documentation. We aimed to explore if a digital handle with instant haptic feedback on traction force would reduce the neonatal risk during low or mid station VAD.

Methods

A two centre, randomised superiority trial at Karolinska University Hospital, Sweden, 2016–2018. Cases were randomised bedside to either a conventional or a digital handle attached to a Bird metal cup (50 mm, 80 kPa). The digital handle measured applied force including an instant notification by vibration when high levels of traction force were predicted according to a predefined algorithm. Primary outcome was a composite of hypoxic ischaemic encephalopathy, intracranial haemorrhage, seizures, death and/or subgaleal hematoma. Three hundred eighty low and mid VAD in each group were estimated to decrease primary outcome from six to 2 %.

Results

After 2 years, an interim analyse was undertaken. Meeting the inclusion criteria, 567 vacuum extractions were randomized to the use of a digital handle (n = 296) or a conventional handle (n = 271). Primary outcome did not differ between the two groups: (2.7% digital handle vs 2.6% conventional handle). The incidence of primary outcome differed significantly between the two delivery wards (4% vs 0.9%, p < 0.05). A recalculation of power revealed that 800 cases would be needed in each group to show a decrease in primary outcome from three to 1 %. This was not feasible, and the study therefore closed.

Conclusions

The incidence of primary outcome was lower than estimated and the study was underpowered. However, the difference between the two delivery wards might reflect varying degree of experience of the technical equipment. An objective documentation of the extraction procedure is an attractive alternative in respect to safety and clinical training. To demonstrate improved safety, a multicentre study is required to reach an adequate cohort. This was beyond the scope of the study.

Trial registration

ClinicalTrials.gov NCT03071783, March 1, 2017, retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03604-z.

The role of sonographic head circumference in the occurrence of subgaleal hemorrhage following vacuum delivery

OBJECTIVE

Subgaleal hemorrhage (SGH) is a severe neonatal morbidity that is associated with vacuum-assisted delivery (VAD). Large sonographic head circumference (sHC) was previously associated with complicated VAD. Nevertheless, the association of large sHC with SGH formation following VAD is underreported. We aim to evaluate the role of sonographic head circumference (sHC) with SGH formation following attempted VAD.

METHODS

A retrospective case-control study. Cases comprised singleton pregnancies for whom attempted VAD resulted in SGH with an sHC measured within 2 weeks from delivery. Controls were VAD deliveries which not resulted in SGH, with an sHC measured within 2 weeks from delivery. We matched controls in a 1:1 ratio by gestational age, parity and year of delivery.

RESULTS

Overall, 118 women were included in the SGH study group and were matched to 118 controls. Baseline maternal and fetal characteristics were similar between the groups except for higher neonatal birth weight in the SGH group (median 3422 vs. 3195 grams, p = .001). sHC did not vary between groups (median 336 mm in SGH groups vs. 333, p = .08). Rate of sHC >90th and >95th percentile did not significantly differ between the groups (13.6% vs. 8.5%, 6.8% vs. 3.4%, p = .21, p = .37, for SGH vs. controls, respectively). In multivariate regression analysis, sHC was not found to be independently associated with SGH - aOR (95% CI) 1.004 (0.97-1.03). Receiver operating characteristic curves of sHC for SGH formation underlined an area under the curve of 0.58 (95% CI) (0.51-0.65).

CONCLUSIONS

sHC is not associated with SGH formation following VAD.

Neonatal and maternal outcome of small-for-gestational-age neonates delivered by vacuum-assisted delivery

OBJECTIVE

To evaluate the association between neonatal weight centile and neonatal and maternal morbidity following vacuum-assisted delivery (VAD) among term nulliparous women.

METHODS

A retrospective cohort study of all nulliparous women who delivered at term by VAD between 2011 and 2019. Deliveries were allocated into two groups and compared: (1) delivery of an small-for-gestational-age (SGA) neonate, and (2) delivery of an appropriate-for-gestational-age (AGA) neonate.

RESULTS

Overall, 3116 women were included in the study; 2878 (92.4%) were AGA and 163 (5.2%) were SGA and comprised the study groups. Neonatal and maternal adverse outcomes did not vary between groups. Rates of composite neonatal adverse outcome for SGA and AGA neonates were 26 (16.0%) versus 462 (16.1%), respectively (P = 0.972). Duration of the second stage of labor and rate of prolonged second stage were significantly lower among the SGA group compared with the AGA group (P < 0.001 for both comparisons). Maternal rates of anal sphincter injury and postpartum hemorrhage did not differ between groups.

CONCLUSION

Neonatal outcomes among SGA neonates delivered by VAD at term did not differ from those of AGA neonates. Maternal outcome did not differ. These data provide reassurance for practitioners to perform VAD in SGA neonates at term.

Neonatal subgaleal hemorrhage unrelated to assisted vaginal delivery: clinical course and outcomes

PURPOSE

The purpose of the study was to evaluate the occurrence of subgaleal hemorrhage (SGH) following non-assisted vaginal delivery (normal vaginal delivery or cesarean delivery), and to characterize associated factors, clinical course, and outcomes, compared to attempted assisted vaginal delivery (AVD)-associated SGH METHODS: A retrospective cohort study was conducted. All cases of SGH encountered following delivery of a singleton neonate at Hadassah, Hebrew University Medical Center during 2011-2018 were included. Maternal, fetal, intrapartum, and neonatal characteristics and outcomes were compared between AVD-related and non-AVD-related SGH groups.

RESULTS

The overall incidence of SGH was 4.5/1000 (369/82,256) singleton deliveries. The incidences of AVD- and non-AVD-related SGH were 44.6/1000 (350/7852) and 0.3/1000 (19/74,404) singleton deliveries, respectively. Ten (53%) of the 19 non-AVD-related SGH were diagnosed after vaginal delivery and 9 (47%) after an urgent cesarean section. SGH severity was mild, moderate, and severe in 68%, 16%, and 16% of the cases, respectively. SGH severity did not differ between the attempted AVD group and the non-AVD-related SGH group. A higher proportion of neonates with non-AVD SGH required phototherapy treatment than did those diagnosed with AVD-related SGH (56% vs. 24%, P = 0.003). Other neonatal outcomes, including Apgar scores, maximal bilirubin level, length of stay, and the rate of composite adverse outcomes, did not differ between the groups.

CONCLUSIONS

SGH, although rare, may be diagnosed after unassisted vaginal or cesarean delivery in the absence of an AVD attempt. We advocate continuing education for all medical staff who participate in peripartum and neonatal care, regarding the possible occurrence of non-AVD-related SGH.