When a baby is born with the help of vacuum extraction or forceps, families may not expect complications beyond the relief of a safe delivery. But in rare cases, a serious scalp bleed called subgaleal hemorrhage can develop in the hours after birth. This condition is uncommon, but it requires urgent medical attention because it can lead to life-threatening blood loss in a newborn.

Subgaleal hemorrhage happens when blood collects in a large space beneath the scalp, between the skull’s outer layer and the tissue that covers it. Because this space extends across the entire top and sides of a baby’s head, it can hold a significant amount of blood relative to a newborn’s small body. If the bleeding is not recognized and treated quickly, it can cause shock, organ damage, and other serious complications.

Most families have never heard of subgaleal hemorrhage before it happens. Understanding what it is, how to recognize the warning signs, and what emergency care involves can help parents feel more prepared and informed if their baby is at risk. This page explains the medical facts about subgaleal hemorrhage in straightforward terms, with a focus on supporting families through a frightening and uncertain time.

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What Is Subgaleal Hemorrhage And Where Does The Bleeding Occur?

Subgaleal hemorrhage is a type of scalp bleed that occurs in the subgaleal space, a layer of loose tissue that sits between the bone of the skull (covered by a thin membrane called the periosteum) and a thick sheet of connective tissue known as the galea aponeurotica. This space is not normally filled with anything, but it can expand when blood accumulates there.

What makes this space particularly dangerous is its size. Unlike other types of scalp swelling that stay in one spot, the subgaleal space extends over the entire dome of the skull, from the forehead to the back of the head and down to the ears and neck. It crosses the natural seams in a baby’s skull, called suture lines, which means the bleeding can spread widely.

Small veins called emissary veins run through this space, connecting blood vessels on the scalp to those inside the skull. During a difficult birth, especially when instruments like vacuum extractors are used, these veins can tear. Blood then seeps into the subgaleal space, where it can continue to accumulate. A newborn’s entire blood volume is small, so losing even a moderate amount of blood into this space can quickly become dangerous.

How Common Is Subgaleal Hemorrhage In Newborns?

Subgaleal hemorrhage is rare in the general population of babies. Studies estimate that it happens in roughly 2 to 3 out of every 1,000 live births overall. However, the risk is much higher when a baby is delivered with the help of a vacuum extractor, one of the main tools used in assisted vaginal deliveries.

Among babies born with vacuum assistance, the incidence of subgaleal hemorrhage increases significantly, though exact rates vary depending on the study and the clinical setting. It is widely recognized as one of the more serious potential complications of vacuum delivery, even though most vacuum-assisted births do not result in this injury.

Historically, subgaleal hemorrhage has carried a high risk of death or severe complications. Older studies reported mortality rates of 20 to 25 percent among infants who required intensive care for this condition. More recent research suggests that outcomes have improved as hospitals have adopted standardized monitoring protocols and rapid treatment approaches, but the condition remains a medical emergency that requires immediate and aggressive care.

What Causes Subgaleal Hemorrhage During Delivery?

The vast majority of subgaleal hemorrhages occur after difficult or instrument-assisted vaginal births. The primary cause is trauma to the scalp during delivery, which tears the small veins in the subgaleal space.

Vacuum extraction is the most strongly associated risk factor. When a vacuum cup is placed on a baby’s head and suction is applied to help guide the baby through the birth canal, the pulling force and the pressure from the device can damage the fragile blood vessels in the scalp. Forceps, another type of delivery instrument, can also cause subgaleal hemorrhage, though the association is somewhat less common.

Several specific circumstances during vacuum or forceps deliveries increase the risk:

Prolonged or repeated vacuum attempts that involve multiple pulls or repositioning of the cup
Cup dislodgements, when the vacuum cup pops off the baby’s head during delivery and has to be reapplied
Higher fetal head station, meaning the baby’s head is still relatively high in the birth canal when the vacuum is applied
Longer duration of the second stage of labor, the pushing phase before delivery
Presence of caput succedaneum, a normal swelling of the scalp that can occur during labor and may make vacuum application more difficult
Use of both vacuum and forceps sequentially, which compounds the trauma to the scalp

Other factors that can contribute to subgaleal hemorrhage include larger birth weight, lower gestational age, signs of fetal distress during labor, and the presence of meconium (the baby’s first stool) in the amniotic fluid.

In some cases, underlying bleeding disorders in the baby can make subgaleal hemorrhage more likely or more severe. These include conditions like hemophilia, low platelet counts, or vitamin K deficiency, which affects blood clotting. Babies whose mothers took certain blood-thinning medications during pregnancy may also be at higher risk.

How Can You Recognize The Signs Of Subgaleal Hemorrhage?

Subgaleal hemorrhage may not be immediately obvious at birth. The bleeding often develops and worsens over the first several hours after delivery, so the signs can be subtle at first and then progress rapidly.

The hallmark physical finding is a soft, boggy swelling on the baby’s scalp. Unlike other types of scalp swelling, this one:

Feels fluid-filled and squishy when touched
Spreads across the entire top and sides of the head
Crosses over the natural seams in the skull (the suture lines)
May shift or move with gravity when the baby’s position changes
Grows larger over time rather than staying the same size or shrinking

As the bleeding continues, the baby’s head circumference will increase measurably, sometimes by several centimeters in just a few hours. Blood may also track forward and downward, causing bruising around the eyes and ears, swelling of the eyelids, and puffiness extending to the neck.

The most concerning signs are systemic, meaning they affect the baby’s overall condition. Because the baby is losing blood volume, signs of shock and poor circulation may appear:

Pale or grayish skin color
Fast heart rate (tachycardia)
Rapid or labored breathing
Cool hands and feet
Weak muscle tone or floppiness
Irritability or unusual fussiness
Poor feeding
Lethargy or decreased responsiveness

If the blood loss is severe, the baby may develop low blood pressure, difficulty breathing, seizures, or life-threatening shock. Metabolic acidosis, a dangerous shift in the body’s chemistry caused by poor oxygen delivery to tissues, can also occur.

Any baby with a swelling scalp after a vacuum or forceps delivery needs close monitoring. If the swelling is growing, if the baby seems unwell, or if any of the warning signs above appear, immediate medical evaluation is necessary.

How Is Subgaleal Hemorrhage Different From Other Types Of Scalp Swelling?

Newborns can develop several types of scalp swelling during or after birth, and not all of them are dangerous. Understanding the differences helps families and healthcare providers recognize subgaleal hemorrhage early.

Caput succedaneum is the most common type of scalp swelling. It is caused by pressure on the baby’s head during labor and consists of fluid and swelling in the soft tissues just under the skin. Caput is usually present right at birth, feels soft and puffy, crosses suture lines, and begins to resolve within a day or two. It does not cause systemic symptoms and is not considered a serious problem.

Cephalohematoma is a collection of blood between the skull bone and the periosteum, the membrane that covers the bone. Unlike subgaleal hemorrhage, cephalohematoma is confined to one bone of the skull and does not cross suture lines. It typically appears as a firm, raised bump on one side of the head that develops within the first day after birth and may take weeks to fully resolve. Cephalohematoma can cause jaundice as the blood breaks down, but it rarely causes the severe blood loss and shock seen with subgaleal hemorrhage.

Subgaleal hemorrhage sits between these two conditions in terms of location but is far more serious. It lies deeper than caput but more superficial than cephalohematoma, and it can spread across the entire scalp because the subgaleal space is not divided by suture lines. The key distinguishing features are the fluctuant, shifting quality of the swelling, the progressive enlargement, and the development of systemic signs like pallor, tachycardia, and shock.

Point-of-care ultrasound is increasingly used in neonatal units and emergency settings to help distinguish these conditions. Ultrasound can show whether a collection of blood is localized under the skull bone (cephalohematoma) or spread widely in the subgaleal space.

How Do Doctors Diagnose Subgaleal Hemorrhage?

The diagnosis of subgaleal hemorrhage is primarily clinical, based on the combination of a high-risk delivery history and physical examination findings. If a baby was born with vacuum or forceps assistance and develops a boggy, enlarging scalp swelling along with signs of blood loss, subgaleal hemorrhage is strongly suspected.

Healthcare providers will perform repeated physical exams in the hours after birth, checking the baby’s scalp, measuring head circumference, and monitoring vital signs. Serial measurements are critical because the bleeding and swelling progress over time.

Laboratory tests are used to assess the severity of the blood loss and detect complications:

Hematocrit and hemoglobin levels measure how much blood the baby has lost
Platelet count and coagulation studies (such as prothrombin time and partial thromboplastin time) check for bleeding disorders or problems with blood clotting
Blood gas analysis evaluates oxygen levels, carbon dioxide, and acid-base balance to detect metabolic acidosis
Blood type and crossmatch prepare for possible transfusion

Imaging studies like cranial ultrasound, CT scan, or MRI may be performed to evaluate for other injuries, such as skull fractures, bleeding inside the skull (intracranial hemorrhage), or brain injury. However, imaging is not required to diagnose subgaleal hemorrhage itself, which can be identified through physical examination.

Most hospitals with high-risk obstetric units or neonatal intensive care units have protocols in place to monitor all babies born after difficult vacuum or forceps deliveries. These protocols include frequent vital sign checks, head circumference measurements, and scheduled lab draws to catch subgaleal hemorrhage as early as possible.

What Emergency Treatment Is Needed For Subgaleal Hemorrhage?

Subgaleal hemorrhage is treated as a neonatal emergency. The priority is to stabilize the baby’s circulation, replace lost blood volume, and prevent life-threatening complications like shock and organ failure.

Initial resuscitation focuses on the ABCs: airway, breathing, and circulation. If the baby is in respiratory distress, oxygen is provided, and some babies may need help breathing with a ventilator. Intravenous (IV) lines are placed to give fluids and medications quickly.

Volume resuscitation is the cornerstone of treatment. Babies with subgaleal hemorrhage often need large amounts of fluid to replace what they have lost into the scalp. This typically includes:

Repeated boluses of isotonic saline or other IV fluids to restore blood pressure and circulation
Packed red blood cell transfusions to replace lost blood and improve oxygen delivery
Fresh frozen plasma or platelet transfusions if the baby has developed a clotting disorder

The amount of blood a baby can lose into the subgaleal space can be startling. Term newborns have a total blood volume of only about 80 to 100 milliliters per kilogram of body weight, and studies show that babies with severe subgaleal hemorrhage can lose 50 to 70 percent of their circulating blood volume.

Ongoing monitoring in a neonatal intensive care unit (NICU) is essential. Babies are placed on continuous cardiorespiratory monitors to track heart rate, breathing, and oxygen levels. Blood tests are repeated frequently to monitor hemoglobin, hematocrit, and clotting function. The medical team watches for signs of complications such as kidney injury, seizures, or worsening acidosis.

Correction of coagulopathy is another key aspect of treatment. Severe blood loss can trigger disseminated intravascular coagulation (DIC), a condition in which the body’s clotting system becomes overactive and then exhausted, leading to both clotting and uncontrolled bleeding. If DIC develops, it is treated with transfusions of clotting factors, platelets, and sometimes additional medications.

Head wrapping or compression has been proposed in some older literature as a way to limit bleeding, but it is not routinely recommended. Applying pressure to the scalp is difficult to do effectively, and if there is also swelling or bleeding inside the skull, compression could worsen intracranial pressure.

There is no surgical procedure to drain the blood from the subgaleal space. The body will gradually reabsorb the blood over days to weeks once the bleeding has stopped. The focus of medical care is supporting the baby through the acute crisis and preventing complications.

What Complications Can Develop From Subgaleal Hemorrhage?

Subgaleal hemorrhage can lead to a cascade of serious medical problems, especially if it is not recognized and treated promptly.

Hypovolemic shock is the most immediate threat. As blood accumulates in the scalp, the amount of blood circulating through the body drops. This reduces oxygen delivery to vital organs, leading to low blood pressure, poor perfusion, and eventually organ failure if not corrected.

Severe anemia results from the blood loss. Even after transfusion, some babies remain anemic for days or weeks and may need additional transfusions during their recovery.

Coagulopathy and disseminated intravascular coagulation (DIC) can develop as the body’s clotting system is overwhelmed. This makes it harder to stop the bleeding and can cause bleeding in other parts of the body, including the brain and internal organs.

Metabolic acidosis occurs when tissues do not get enough oxygen and begin producing lactic acid. This shifts the body’s pH balance and can impair heart and lung function.

Seizures may occur due to low oxygen levels, changes in blood chemistry, or direct injury to the brain. Seizures in the newborn period require urgent treatment and may be a sign of hypoxic-ischemic encephalopathy, a type of brain injury caused by lack of oxygen.

Kidney injury can result from prolonged low blood pressure and poor perfusion. In severe cases, babies may develop acute kidney failure requiring dialysis.

Hypoxic-ischemic encephalopathy (HIE) is one of the most serious complications. When a baby’s brain does not receive adequate oxygen due to shock and low blood pressure, brain cells can be damaged or die. HIE can lead to long-term neurological problems, including developmental delays, cerebral palsy, and intellectual disability.

Jaundice often develops as the large volume of blood in the scalp breaks down. The baby’s liver may struggle to process the bilirubin (a breakdown product of red blood cells), leading to high bilirubin levels that require treatment with phototherapy (light therapy) or, in severe cases, exchange transfusion.

The risk of these complications is why subgaleal hemorrhage is considered a medical emergency. The faster the bleeding is recognized and treatment is started, the better the chance of preventing long-term harm.

What Is The Long-Term Prognosis For Babies With Subgaleal Hemorrhage?

The long-term outcome for a baby who has had subgaleal hemorrhage depends largely on how severe the bleeding was and whether complications developed.

Babies with mild to moderate subgaleal hemorrhage who receive prompt treatment and do not develop shock or significant oxygen deprivation generally have a good prognosis. Many of these infants recover fully without lasting neurological effects. However, even in mild cases, careful developmental follow-up is recommended to monitor for any subtle delays that might emerge as the child grows.

Babies who experience severe subgaleal hemorrhage with significant blood loss, prolonged shock, low Apgar scores, seizures, or multi-organ injury are at higher risk for adverse outcomes. Studies of long-term prognosis show that survivors who had severe presentations are more likely to have developmental delays, motor impairments, learning difficulties, or cerebral palsy.

The presence of hypoxic-ischemic encephalopathy (brain injury from lack of oxygen) is one of the strongest predictors of poor neurodevelopmental outcomes. Babies who undergo therapeutic hypothermia (cooling treatment) for HIE associated with subgaleal hemorrhage will need ongoing neurological assessment and early intervention services.

Even when the acute crisis is over, families should expect regular follow-up with pediatricians, neurologists, and developmental specialists. Many babies benefit from early intervention programs that provide physical therapy, occupational therapy, speech therapy, and support for developmental milestones.

How Can Subgaleal Hemorrhage Be Prevented?

Subgaleal hemorrhage is considered largely preventable through careful obstetric technique and strict adherence to safety guidelines for operative vaginal delivery.

Professional organizations such as the American College of Obstetricians and Gynecologists (ACOG) emphasize that vacuum extractors and forceps should only be used when there is a clear medical indication, such as a prolonged second stage of labor or signs of fetal distress that require expedited delivery. The decision to use these instruments should be made carefully, weighing the risks and benefits.

Key principles for safe vacuum extraction include:

Proper positioning and placement of the vacuum cup on the baby’s head, ideally over the sagittal suture and several centimeters in front of the posterior fontanelle
Limiting the number of pulls or traction attempts
Avoiding prolonged vacuum application (most guidelines recommend no more than 15 to 20 minutes of active pulling)
Stopping the procedure after a certain number of cup detachments (commonly three) or if no progress is being made
Avoiding the sequential use of vacuum and forceps, which increases the risk of trauma

Monitoring for the development of caput succedaneum during labor can also be important. If significant scalp swelling is already present, the vacuum cup may not apply as effectively, and the risk of further trauma may be higher.

Training and skill are critical. Providers who perform operative vaginal deliveries need adequate experience and supervision, especially when learning the techniques. Simulation training and quality improvement programs can help reduce complications.

The U.S. Food and Drug Administration (FDA) has issued safety advisories about vacuum extraction devices, highlighting the risk of serious cranial hemorrhages, including subgaleal hemorrhage, and emphasizing the need for proper technique and vigilant neonatal monitoring.

After any vacuum or forceps delivery, hospitals should have protocols in place to observe the baby closely for the first 12 to 24 hours. This includes regular checks of the scalp, head circumference, vital signs, and overall well-being. Early detection is the next best line of defense when prevention is not possible.

What Support And Resources Are Available For Families?

Subgaleal hemorrhage is a frightening experience for families. Watching a newborn in crisis, undergoing transfusions, and facing the possibility of long-term complications can be overwhelming.

Babies with subgaleal hemorrhage are typically cared for in a neonatal intensive care unit (NICU) with access to pediatric subspecialists. This may include neonatologists, pediatric neurologists, hematologists, and developmental pediatricians. In New York, major medical centers such as NYU Langone, Columbia University Medical Center, Mount Sinai, and Albany Medical Center have advanced NICUs equipped to handle complex neonatal emergencies and provide multidisciplinary follow-up.

Clear communication from the medical team is essential. Families need explanations of what is happening, why certain treatments are being given, what complications to watch for, and what the plan is for monitoring and follow-up. Social workers and patient advocates within the hospital can provide additional support and help families navigate insurance, transportation, and other logistical challenges.

If a baby develops long-term neurological problems as a result of subgaleal hemorrhage, early intervention services can make a significant difference. In New York, the Early Intervention Program provides services for infants and toddlers with developmental delays or disabilities, including physical therapy, occupational therapy, speech therapy, and special instruction. Families can contact their local county health department or regional Early Intervention office to learn about eligibility and services.

Support groups for parents of babies who have experienced birth complications can provide emotional support and practical advice. Connecting with other families who have gone through similar experiences can help parents feel less isolated.

Developmental follow-up is a long-term process. Regular assessments with pediatricians and developmental specialists help identify any emerging delays early, so that interventions can be started promptly. Physical and occupational therapy can address motor skills, while speech therapy and educational support can help with communication and learning.

Families who have questions about the care their baby received, or who are concerned that the subgaleal hemorrhage might have been preventable, may benefit from consulting with medical advocates or legal professionals who specialize in birth injury cases. These consultations can help families understand what happened, whether standards of care were met, and what options might be available to support their child’s needs.

Subgaleal Hemorrhage