Cephalohaematoma

Cephalohaematoma is a subperiosteal collection of blood over the skull. It does not cross suture lines because the periosteum is attached at the sutures, which distinguishes it from subgaleal haemorrhage.

It occurs in 1 to 2% of births, usually over the parietal bone, and is bilateral in about 10 to 20%. It appears within the first hours to days of life and enlarges over 2 to 3 days.

Risk factors are instrumental delivery (vacuum or forceps), prolonged labour, primiparity and macrosomia. A linear skull fracture underlies the haematoma in about 5 to 25%.

Pathophysiology.

Shearing forces during delivery tear periosteal vessels, which bleed slowly under the periosteum. The blood is resorbed over weeks, and the periosteum can lay down bone around the edges, forming a calcified rim.

Resorption of a large collection raises bilirubin load, so jaundice can be prolonged.

• Firm, well defined swelling over one or both parietal bones, which appears hours after birth, is not tender, and does not cross the midline or suture lines.
• Overlying skin is normal in colour.
• Complications: hyperbilirubinaemia, anaemia (uncommon), calcification and, rarely, infection or osteomyelitis.

Red flags.

• Fever, redness, tenderness or discharge over the swelling.
• Neurological signs, a depressed skull fracture or bulging fontanelle.
• Rapid enlargement or pallor, which suggests subgaleal haemorrhage or a coagulopathy.

• Clinical diagnosis by the swelling's limits at sutures and its timing.
• Skull X-ray, ultrasound or CT is needed only if there are neurological signs, a depressed fracture is suspected or the swelling is atypical.
• Serial bilirubin when large or bilateral, haemoglobin in large collections, and a coagulation screen with a family history of bleeding.

Differential diagnosis. Caput succedaneum (present at birth, crosses sutures, resolves in days), subgaleal haemorrhage, encephalocele and scalp injuries.

• Observe. Most resolve over 2 weeks to 3 months. Calcified lesions can persist for months and rarely need surgery.
• Do not aspirate or incise because of the risk of infection.
• Check vitamin K was given. Monitor bilirubin and treat with phototherapy using the gestation specific and age specific chart.
• Infection signs need blood culture, and IV antibiotics (flucloxacillin 50 mg/kg every 8 hours in infants over 7 days of age, with gentamicin adjusted to gestation and age), with imaging for osteomyelitis and drainage if collections are infected.
• Transfuse only for symptomatic anaemia after large bleeds.

Monitoring. Examination at discharge and at 6 to 8 weeks. Bilirubin at 24 to 48 hours for large collections.

Referral and escalation. Refer to neurosurgery for depressed fracture or persistent calcified deformity, and to paediatrics for suspected infection or coagulopathy.