a heads up on subgaleal hemorrhage - children's · pdf filea heads up on subgaleal...
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![Page 1: A Heads Up on Subgaleal Hemorrhage - Children's · PDF fileA Heads Up on Subgaleal Hemorrhage Cheryl McDuffie MSN, FNP-C, RNC-NIC. Disclosures ... Case of Baby Jane • Despite NICU](https://reader034.vdocuments.us/reader034/viewer/2022042707/5a72f3ef7f8b9ac0538e372c/html5/thumbnails/1.jpg)
A Heads Up on Subgaleal
HemorrhageCheryl McDuffie MSN, FNP-C, RNC-NIC
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Disclosures• I have nothing to disclose
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Objectives• After this presentation the learners will be
able to:o Differentiate between common scalp swellings and
subgaleal hemorrhageo Identify delivery history and physical assessment findings
which warrant frequent reassessment for signs of subgaleal hemorrhage
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The Case• This is a published case presentation.• Any resemblance to a case in any local
hospital is purely coincidental.• All pictures are publicly available on the
internet. All patient pictures are from published articles in reference list.
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Case of Baby JaneAssessment• 41 week, 3891Gm female• Gravida-1 Para-0• Spontaneous labor• Vacuum extraction vaginal delivery • Tight nuchal cord cut approximately 50
seconds prior to delivery• Mild shoulder dystocia• Apgars 3 @ 1, 4 @ 5, and 7 @ 10 minutes
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Scalp
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http://www.studyblue.com/notes/note/n/exam‐3/deck/6048127
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Scalp swellings
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Scalp swellings• Caput succedaneum
o Serosanguineous fluid in subcutaneous tissues of presenting part
o Soft spongy, crosses suture lines, shifts with positioning
o Minimal blood losso Resolves in 48-72 hours
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Caput succedaneum
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Scalp swellings• Cephalohematoma
o Blood accumulation between skull bone and periosteum
o Does not cross suture lines, initially firmo Location- parietal and occipital bones,
85% unilateralo Blood loss is rarely severeo Resolves in 2 weeks to 3 months
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Cephalohematoma
http://newborns.stanford.edu/PhotoGallery/Cephalohematoma1.html
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Scalp swellings• Subgaleal hemorrhage
o Rupture of the emissary veins, blood accumulation in the subaponeurotic space.
o Massive blood loss possible, no barrier to stop the bleeding.o Space can hold 240ml
• Newborn blood volume 78-86ml/Kg (Harriet Lane, 2012)• 3Kg infant, 80ml/Kg = 240ml
o Space extends from nape of neck to orbits of the eyes and from ear to ear.
o May see fluid waveo Displace ear anteriorlyo Swelling around the eyeso Resolves in 2-3 weeks High morbidity
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http://www.oganatomy.org/projanat/neuroanat/3/eight.htm
http://www.studyblue.com/notes/note/n/11‐27‐12‐3pm‐scalp‐‐cranial‐cavity/deck/4588068
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Subgaleal hemorrhage
http://newborns.stanford.edu/PhotoGallery/Subgaleal3.html
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http://www.ped.si.mahidol.ac.th/e‐diary/makehtml/division/thrathip/birthinjury/birth1.html
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How I think about things…..
Caput
CephalohematomaSubgaleal hemorrhage
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Incidence • 1 in 2500 spontaneous vaginal births• 10 fold increase with the use of forceps or vacuum• Vacuum use is reported in approximately 49% of all
subgaleal hemorrhage (Schierholz, E., Walker, S.R., 2010)
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Vacuum Assisted Delivery
http://www.aafp.org/afp/2008/1015/p953.html
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http://www.kentecmedical.com/manufacturer_detail.phtml?mfg_id=140&pline_id=155&src=cat
http://www.utahmed.com/vacuumdelivery.htm
http://news.thomasnet.com/fullstory/Vacuum‐Assisted‐Delivery‐System‐is‐secure‐and‐gentle‐20004131
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http://en.wikipedia.org/wiki/Ventouse
http://ispub.com/IJPN/5/2/7678
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Risk factors associated with SGH after vacuum‐ assisted delivery
• Nulliparous mother• Failed vacuum extraction• Inadvertent cup release (pop-offs)• Sequential use of vacuum and forceps• Apgar less than 8 @ 5 min following vacuum
assisted delivery• Deflexing cup application (cup edge less than
3 cm from anterior fontanel)• Paramedian cup application (cup centered
more than 1 cm lateral to sagittal suture)(Karlsen, 2013)
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http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/dec16_6(suppl1)/Pages/07.aspx
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What do we place on all newborns?
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Case of Baby JaneAssessment• 41 week, 3891Gm female• Gravida-1 Para-0• Spontaneous labor• Vacuum extraction vaginal delivery • Tight nuchal cord cut approximately 50
seconds prior to delivery• Mild shoulder distocia• Apgars 3 @ 1, 4 @ 5, and 7 @ 10 minutes
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What else would you like to know?
• Question 1• Question 2• Question 3
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How long?• How long was the vacuum in place prior to
delivery?o Time from initiation of vacuum to delivery 21
minutes
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How many?• How many pop-offs?
o “multiple pop-offs”
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Where was the cup placed?
• Where is the chignon (cup mark)?o Unknown
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Case of Baby JaneAssessment• 41 week, 3891Gm female• Gravida-1 Para-0• Spontaneous labor• Vacuum extraction vaginal delivery • Tight nuchal cord cut approximately 50
seconds prior to delivery• Mild shoulder distocia• Apgars 3 @ 1, 4 @ 5, and 7 @ 10 minutes
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Case of Baby Jane• Baby required bag mask ventilation for ~ 4 minutes• On examination “bogginess” of scalp noted• Baby described as flaccid and “shocked” looking• To nursery for observation• 1.5 hrs of life transport called because baby paler
and unresponsive
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Case of Baby Jane• Fluid boluses suggested but no IV access• Transport noted severe swelling of the baby’s scalp• Hct @ 3.5 hrs of life 34 compared to cord Hct 49• Rec’d 50ml/Kg crystalloid and blood plus glucose,
NaHCO3, Dopamine
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Case of Baby Jane• Despite NICU care baby continued to deteriorate
with severe encephalopathy, profound hypotension, renal failure, disseminated intravascular coagulation (DIC), she died at 18 hours of life.
• Postmortem exam confirmed massive subgaleal hemorrhage, with several diastatic fractures and anoxic- ischemic changes within the brain.
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Assessment• Get complete delivery history• Number of pop-offs, length of time with suction• Assess location of suction mark• Initial Head circumference• Reassessment of FOC- each cm increase in FOC =
approximately 40ml of blood loss (Reid, 2007)• Assess for signs of shock- increased HR, decreased
BP, increased cap refill, pallor
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Plan• Diagnostic testing• Blood gas, Hct, clotting studies, • Blood products- Hypovolemic shock• Blood volume replacement (FFP, PRBC)• Platelets and clotting factors (DIC)• Inotropes to maintain adequate blood pressure
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ImplementationNursing care
• Assess and stabilize respiratory status• Assess head and skull for abrasions, ecchymosis,
and swelling• Measure head circumference• Obtain laboratory studies: blood gas, type and
cross, CBC, coagulation studies• Obtain IV access; peripheral vs umbilical• Communicate with family, transport team, and
physicians
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Evaluation• Continued frequent assessment of vital signs,
respiratory status, head examination and laboratory studies
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Did I meet the objectives?• After this presentation the learners will be
able to:o Differentiate between common scalp
swellings and subgaleal hemorrhageo Identify delivery history and physical
assessment findings which warrant frequent reassessment for signs of subgaleal hemorrhage
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References• Chang, H., Peng, C., Kao, H., Hsu, C., Hung, H., Chang, J. Neonatal subgaleal hemorrhage: Clinical
presentation, treatment, and predictors of poor prognosis. Pediatrics International. 49. 903-907.• Davis, D. J. (2001) Neonatal subgaleal hemorrhage: diagnosis and management. Canadian Medical
Association Journal. 164(10). 1452-1453.• Federal Drug Administration (1998) FDA public health advisory: Need for caution when using vacuum
assisted delivery devices. Retrieved on July 8, 2013 from http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/ucm062295.htm.
• Karlsen, K, (2013) The STABLE Program Learner Manual. S.T.A.B.L.E Inc. Salt Lake City, UT.• O’Grady, J.P. (2012) Vacuum extraction. Medscape. Retrieved September 18, 2013 from
http://emedicine.medscape.com/article/271175-overview.• Reid, J. (2007) Neonatal subgaleal hemorrhage. Neonatal Network. 26(4). 219-227.• Schierholz, E., Walker, S.R. (2010) Responding to traumatic birth subgaleal hemorrhage, assessment and
management during transport. Advances in Neonatal Care. 10(6). 311-315.• Tscudy, M.M., Arcara, K.M. (2012) The Harriet Lane Handbook. 19th edition. Elsevier Philadelphia, PA.• Wetzel, E.A., Kingman, P.S. (2012) Subgaleal hemorrhage in a neonate with factor X deficiency following
a non-traumatic cesarean section. Journal of Perinatology. 32. 304-305.