CEPHALHEMATOMA

A cephalohematoma is an accumulation of blood under the scalp. During the birth

process, small blood vessels on the head of the fetus are broken as a result of minor
trauma. Specific to a cephalohematoma, small blood vessels crossing the
periosteum are ruptured and serosanguineous or bloody fluid collects between the
skull and the periosteum. The periosteum is the membrane that covers the outer
surface of all bones. The bleeding is gradual; therefore, a cephalohematoma is not
evident at birth. A cephalohematoma develops during the hours or days following
birth. Because the fluid collection is between the periosteum and the skull, the
boundaries of a cephalohematoma are defined by the underlying bone. In other
words, a cephalohematoma is confined to the area on top of one of the cranial bones
and does not cross the midline or the suture lines. Because the collection of blood
is sitting on top of the skull and not under it, there is no pressure placed on the brain.

ETIOLOGY
The cause of a cephalohematoma is rupture of blood vessels crossing the
periosteum due to the pressure on the fetal head during birth. During the process of
birth, pressure on the skull or the use of forceps or a vacuum extractor rupture these
capillaries resulting in a collection of serosanguineous or bloody fluid. Factors that
increase pressure on the fetal head and the risk of the neonate developing a
cephalhematoma include:
 Long labor
 Prolonged second stage of labor
 Macrosomia
 Weak or ineffective uterine contractions
 Abnormal fetal presentation
 Instrument-assisted delivery with forceps or vacuum extractor
 Multiple gestations
 These factors contribute to the traumatic impact of the birthing process on
the fetal head.

EPIDEMIOLOGY
Cephalohematoma is a subperiosteal accumulation of blood that occurs with an
incidence of 0.4% to 2.5% of all live births. They are more common in
primigravidae, large infants, infants in an occipital posterior or transverse occipital
position at the start of labor, and following instrument-assisted deliveries with
forceps or a vacuum extractor. For unknown reasons, cephalohematomas occur
more often in male than in female infants.

PATHOPHYSIOLOGY
Cephalohematoma is a minor condition that occurs during the birth process.
Pressure on the fetal head ruptures small blood vessels as when the head is
compressed against the maternal pelvis during labor or pressure from forceps or a
vacuum extractor used to assist the birth. Shearing action between the periosteum
and the bone causes bleeding of the emissary and diploic veins. As blood
accumulates, the periosteum lifts away from the skull. As the bleeding continues
and fills the subperiosteal space, pressure builds, and the accumulated blood acts as
a tamponade to stop further bleeding.

HISTORY AND PHYSICAL

A comprehensive history of the labor and birth is needed to identify newborns at
risk of developing a cephalohematoma. Factors that increase pressure on the fetal
head and the risk of developing a cephalhematoma include:
 Long labor
 Prolonged second stage of labor
 Macrosomia
 Weak or ineffective uterine contractions
 Abnormal fetal presentation
 Instrument-assisted delivery with forceps or vacuum extractor
 Multiple gestations

Because of the slow nature of subperiosteal bleeding, cephalohematomas usually

are not present at birth but develop hours or even days after birth. Therefore,
repeated inspection and palpation of the newborn’s head is necessary to identify the
presence of a cephalohematoma. Ongoing assessment to document the appearance
of a cephalohematoma is important. Once a cephalohematoma is present, assessing
and documenting changes in size is continued. The most obvious sign of a
cephalohematoma is a soft, raised area on the newborn’s head. A firm, enlarged
unilateral or bilateral bulge on top of one or more bones below the scalp
characterizes a cephalohematoma. The raised area cannot be transilluminated, and
the overlying skin is usually not discolored or injured. Cranial sutures define the
boundaries of the cephalohematoma. The parietal bones are the most common site
of injury, but a cephalohematoma can occur over any of the cranial bones.

EVALUATION
There is no diagnostic test for a cephalohematoma. Diagnosis is based on the
characteristic bulge on the newborns head. However, some providers may request
additional tests, including x-rays, CT scan, or ultrasound to evaluate for potential
fractures of the skull or other problems below the skull, which could impact the
newborn’s brain. Additional testing is especially warranted if the newborn's
behavior changes or other problems, such as respiratory, cardiovascular, or
neurological are present.
TREATMENT / MANAGEMENT
Treatment and management of a cephalohematoma are primarily
observational. The mass from a cephalohematoma takes weeks to resolve as the
clotted blood is slowly absorbed. Over time, the bulge may feel harder as the
collected blood calcifies. The blood then starts to be reabsorbed. Sometimes the
center of the bulge begins to disappear before the edges do, giving a crater-like
appearance. This is the expected course for the cephalohematoma during
resolution.
One should not attempt to aspirate or drain the cephalohematoma.
Aspiration is not effective because the blood has clotted. Also, entering the
cephalohematoma with a needle increases the risk of infection and abscess
formation. The best treatment is to leave the area alone and give the body time to
reabsorb the collected fluid.
Usually, cephalohematomas do not present any problem to a newborn. The
exception is an increased risk of neonatal jaundice in the first days after birth.
Therefore, the newborn needs to be carefully assessed for a yellowish discoloration
of the skin, sclera, or mucous membranes. Noninvasive measurements with a
transcutaneous bilirubin meter can be used to screen the infant. A serum bilirubin
level should be obtained if the newborn exhibits signs of jaundice.

https://www.ncbi.nlm.nih.gov/books/NBK470192/#_article-19156_s8_

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