Cephalhaematoma following vacuum extraction

Neonatal Subgaleal Hemorrhage and Its Relationship to Delivery by Vacuum Extraction

Subgaleal hemorrhage is a rare condition of the neonate often associated with instrumental delivery. It is a potentially fatal condition that is often underreported and underdiagnosed. The vacuum extractor is being advocated as the instrument of first choice for assisted vaginal delivery, but appears to be associated with an increased incidence of subgaleal hemorrhage. It is widely believed that the vacuum cup will dislodge before causing serious fetal trauma. Because of the ease of application, vacuum extractors could be used potentially in circumstances in which forceps would not be attempted, allowing an operator of average experience to perform rotational deliveries. The worrisome increase in the incidence of subgaleal hemorrhage associated with vacuum extraction leads to the issuance of warnings from governmental authorities in Canada and the United States. This review discusses the anatomy of this lesion, etiology, clinical presentation, management, and possible prevention.

Neonatal subgaleal hematoma causing brain compression: report of two cases and review of the literature

OBJECTIVE AND IMPORTANCE

Neonatal subgaleal hematomas (SGHs) are infrequent but underdiagnosed collections of blood beneath the galea, often caused by vacuum delivery. With massive bleeding into the subgaleal space, exsanguination and hypovolemic shock can cause death in 20 to 60% of newborn infants. We report the first two known patients with extracranial cerebral compression caused by SGH. Also, the surgical evacuation of neonatal SGH has not been described previously.

CLINICAL PRESENTATION

One patient was a full-term boy who was delivered via vacuum extraction after an uncomplicated pregnancy. Within a few hours, he developed an expanding fluid collection of the scalp and disseminated intravascular coagulation and shock requiring intubation, inotropic support, and blood transfusions. His head circumference grew from 33 cm at birth to 42 cm. He became progressively lethargic and developed posturing movements. Computed tomography of the head revealed a massive SGH causing gross overlapping of the cranial sutures and diffuse cerebral edema. The other patient was a full-term boy delivered via cesarean section after an unsuccessful attempt at vacuum extraction and forceps delivery. The initial head circumference was 34 cm. Within a few hours, he developed an expanding fluid collection of the scalp and became progressively lethargic with posturing. Magnetic resonance imaging of the head revealed a massive SGH with cranial compromise and diffuse cerebral edema.

INTERVENTION

Both children had radiographic features indicative of elevated intracranial pressure as well as neurological decompensation. The first patient was taken to the operating room, and the hematoma was evacuated through a small scalp incision. Initially, approximately 150 ml of blood was removed, and a Jackson-Pratt drain diverted another 200 ml of blood during the next 2 days. The infant made a good recovery. In the second case, the patient remained too unstable for operative intervention and died.

CONCLUSION

Extracranial cerebral compression represents another way by which neonatal SGH may jeopardize the infant's life. Management consists of measures to correct hypovolemic shock and disseminated intravascular coagulation, as well as surgical intervention to control elevated intracranial pressure.

Impact of FDA advisory on reported vacuum-assisted delivery and morbidity

OBJECTIVE

In May 1998 the US Food and Drug Administration (FDA) issued a health advisory reporting neonatal injuries/deaths following vacuum delivery and encouraged voluntary reports of future adverse events. We compared FDA reports of vacuum delivery adverse events prior to and following the advisory.

METHODS

The FDA database (MAUDE) was searched for vacuum deliveries using brand name, manufacturer name, and procedure "string searches." Cases were sorted by report date, source, and manufacturer. Neonatal morbidity was quantified as deaths and life-threatening or nonlife-threatening events.

RESULTS

A total of 80 reported adverse cases were identified after duplicate cases were consolidated. Twenty-five were reported to the FDA prior to the 1998 advisory and 55 in the immediate 6-month period following the advisory. There was a 22-fold increase in reported events from five events/year prior to the advisory to an estimated 110 events/year following the advisory. The distribution of reporting sources changed significantly following the advisory with increased "manufacturer" (8-43%) and decreased "voluntary" reports (56-20%). All major brand names were represented. During the 6 months following the FDA advisory there were 10 neonatal deaths, 30 life-threatening events, 12 nonlife-threatening events, and three equipment-related reports. Infant deaths were due to intracranial or subgaleal hematomas. Injuries included skull fracture, scalp abrasions, and cephalohematomas.

CONCLUSIONS

The FDA advisory was associated with a 22-fold increase in the rate of reported adverse events. This increase in reporting likely represents both enhanced awareness of complications as well as an increase in vacuum-related adverse neonatal sequelae. As vacuum delivery is associated with greater neonatal morbidity/ mortality than was previously recognized, the adage that the vacuum is "designed to come off before infant damage occurs" appears unsubstantiated. It is recommended that manufacturers quantify the suction and traction capabilities of present and new proposed vacuum cup designs.

Neonatal subgaleal haematoma: associated risk factors, complications and outcome

OBJECTIVE

To describe the obstetric and perinatal factors, in particular the method of delivery, associated with development of a subgaleal haematoma (SGH) and to determine the outcome of survivors with this type of birth trauma.

METHODOLOGY

Perinatal and obstetric data were retrospectively reviewed for 37 infants admitted to the neonatal unit of the sole tertiary paediatric referral hospital in Western Australia with an SGH, over a 24 year period from 1970 to 1993. These data were compared to data for all Western Australian births. The long-term outcome was obtained through medical and private paediatric records for 26 of these infants.

RESULTS

All except one of the neonates had instrumental deliveries; 89% had a vacuum extractor applied to the head at some stage of delivery compared to 10% of the general population of births in Western Australia. There was also a significantly increased risk of failure of attempted vacuum extraction. Of the cases where a vacuum extraction was attempted, 45% also had forceps applied to the head. Coagulopathy was associated with the severity of the SGH. There was also a high frequency of occurrence (40%) of associated head trauma such as intracranial haemorrhage, skull fracture and cerebral oedema, as well as neonatal encephalopathy (73%). The occurrence of these associated features did not correlate significantly with the severity of SGH. Minor complications of SGH included jaundice and facial bruising. There was an excess mortality associated with SGH; however, the long-term outcome for neonatal survivors with this disorder was good. None of the cases studied subsequently developed cerebral palsy or intellectual disability, and minor neurological sequelae only were documented in four infants.

CONCLUSIONS

SGH is an uncommon type of birth trauma, and is associated with delivery or attempted delivery by vacuum extraction. The most commonly associated clinical problems were hypovolaemia and coagulopathy. The long-term outcome for neonates with this condition is good.

Vacuum extraction and forceps delivery in a district hospital

We compared 302 vacuum extractions and 205 forceps deliveries at Fairfield District Hospital, Sydney, over a period of 30 months. Age, parity, gestational age, length of labour and birth-weight were not significantly different between the 2 groups. Significantly less analgesia was required for mothers whose babies were delivered by vacuum extraction compared with mothers with forceps deliveries (p less than 0.01). Average blood loss was slightly higher during forceps delivery as compared with vacuum extraction and there was a significantly higher incidence of postpartum haemorrhage after forceps delivery (p less than 0.05). More babies were jaundiced after vacuum extraction and more required phototherapy, but the differences were slight and were not statistically significant. We conclude that vacuum extraction is a useful and safe alternative to forceps delivery in a district hospital setting.

Skull subcutaneous emphysema--a rare complication of vacuum extraction and scalp electrode

A full-term newborn infant with severe subcutaneous emphysema of the skull as a complication of vacuum extraction and scalp electrode wound is reported. We hypothesize that detachment of subcutaneous tissue and transmission of the negative pressure associated with the vacuum extraction resulted in entry of air through the scalp electrode wound.

Vacuum extractor: a safe instrument?

One thousand five hundred and twenty-six records of deliveries with vacuum extractor in 1982 and 1983 in the Hong Kong University Department of Obstetrics and Gynaecology were reviewed. Vacuum extractor was found to be easy and safe to use even by inexperienced house-staff. Vacuum extractor was especially useful in the delivery of malpositioned fetal heads because of its mechanism of allowing autorotation. Its advantage of not occupying extra space in the pelvis was most beneficial to the relatively smaller Chinese pelvis. Maternal injury was uncommon. Fetal scalp injury like cephalhaematoma was not uncommon but serious scalp injury was infrequent. Perinatal mortality rate attributed to the instrument was low (0.6/1,000). However, in order to achieve safety to the mother and fetus, strict rules in application of the vacuum extractor must be observed.

Cephalhematoma in the newborn

A chart survey of 139 newborns with cephal hematoma showed the majority were associated with primiparity, forceps delivery, or prolonged labor. The complications included jaundice, central nervous system symptoms, localized in fection, anemia and subdural hematoma. Neo natal jaundice was frequently associated. Under lying skull fractures were found in 7.1 per cent of the 84 infants in whom skull x-rays were taken, a lower incidence than that reported by others.