Subdural haematoma in neonates following forceps-assisted delivery: case series and review of the literature

Instrumental delivery is performed for 5–20% of infants in developed countries [1] with a median estimate of 7.5% in Europe [2]. Although recent trends show a preference towards the use of vacuum devices [3], forceps-assisted delivery (FAD) continues to be used widely. Maternal complications of FAD include post-partum bleeding, anal sphincter injuries, and psychological trauma [4]. Use of forceps to grasp the baby’s head can result in significant foetal injury, including subgaleal haematoma, facial trauma, neonatal jaundice, and retinal haemorrhages [5]. One recognised complication is the development of a subdural haematoma (SDH) (Fig. 1). This tends to present within 24 h of birth with hypotonia, respiratory distress, seizures, and/or a tense fontanelle [6]. Management usually requires liaison with neurosurgical and intensive care teams. Currently, there are no guidelines regarding management of post-FAD SDH and their outcomes are yet to be fully explored. In this study, we aim to provide better insight into the management of neonatal SDH post-FAD by (1) presenting similar cases from our unit, and (2) summarising a review of the literature regarding its presentation, management, and outcomes.

Using the same criteria as the literature review, we have identified four cases of post-FAD SDH in our unit.

A total of nine full-text articles were yielded from our literature search (see Table 1). The majority were case series [6, 8‐11, 15], with two retrospective studies [12, 14] and one prospective study [13]. A total of 30 patients were identified across evaluated articles that fit our inclusion criteria.

Development of SDH in neonates is an uncommon but recognised complication of FAD. In this review, we have reported both our personal experience with management of this condition and evaluated the literature for similar cases. The risk of post-FAD SDH likely emerges from a combination of (1) evolution of a comparatively narrow female pelvis compared to her primate ancestors and increased brain volume of the newborn at birth [16] and (2) prolonged instrumental manipulation of newborn’s deformable skull during delivery.

Of the four cases reported from our unit, three were males, which was consistent with the male preponderance observed in evaluated studies. The reason for this is unclear, but further evidence is required to support possible male susceptibility to post-FAD SDH. Birth weight in all four neonates was variable. Average birthweight in evaluated studies was 3276 g, which is similar to the average birth weight of babies of European heritage [17]. Indeed, there is no evidence for a relationship between birthweight and risk of sustaining SDH. In our cases, FAD alone was performed without initial failed ventouse delivery, although the procedure was abandoned and emergency C-section was performed in one case. It is possible that failed ventouse delivery prior to FAD increases the risk of neonatal SDH. One study [13] prospectively studied the frequency of clinically silent subdural haemorrhage in 111 neonates on MRI. When compared to other subgroups, FAD following failed ventouse delivery resulted in a greater risk of SDH, which was statistically significant. Although this applies to clinically silent SDH, it is unclear whether this can be generalised to all cases of neonatal SDH post-FAD. This observed risk could be due to the protracted delivery and instrumental manipulation of the neonatal head rather than the choice of instrument as such. Further studies recording duration of attempted instrumental delivery may help stratify risk of intracranial bleeding.

Clinical presentation is acute, but not necessarily reflected by condition immediately following birth. APGAR scores improved between 1 and 5 min across our cases, and this is corroborated by findings across included studies. Non-specific neurological symptoms begin to manifest over the first 24 h following birth, typically with hypotonia or lethargy, or more dramatically with onset of seizures as demonstrated in three of our cases. Other presenting features such as facial nerve palsy, proptosis, or cephalhaematoma (see Table 3) are more likely to be the result of craniofacial trauma from instrumental use. Nonetheless, they are indicative of the possibility of underlying intracranial damage. Delayed deterioration with features of raised ICP may be a result of hydrocephalus [10]. Ultrasound (USS) as first line imaging for detection of SDH demonstrated mixed success in included studies [6, 14]. However, one study [14] demonstrated effective use of USS for detection of hydrocephalus. Given that a large proportion of surgically managed patients had hydrocephalus, USS may be useful in this situation. USS was used in one of our patients but did not detect SDH, which was demonstrated in the subsequent CT. Therefore, CT head should be performed where possible if there is clinical suspicion of neonatal SDH. The effect of accompanying intracranial bleed on presentation, management, and outcomes is unclear. Two of our cases had accompanying EDH, and two had accompanying ICH. Included studies reported isolated SDH in approximately two thirds of cases. Complexity of injury and difficulty of imaging interpretation suggest that isolated SDH is less common. It is unclear whether the anatomical location of SDH affects presentation or outcomes. For instance, posterior fossa SDH confers the risk of brainstem compression and hydrocephalus (Fig. 2) but further studies are required to confirm whether prognosis is worse than neonatal SDH in other locations. Two of our patients (Case 2 and 3) had posterior fossa SDH and presented with symptoms of respiratory distress, but this was no different to the other cases. Thus, it is unclear whether location of SDH should influence risk stratification or management.

Management of neonatal SDH post-FAD requires joint care between neurosurgical and neonatal intensive care team. The general paradigm involves seizure control, ventilatory support when required, and close monitoring for further deterioration and neurosurgical intervention. In more than half of cases, conservative management is sufficient, demonstrated by full recovery in 93.8% from included studies. This is consistent with our own experience, as all four cases were managed conservatively with no evidence of neurological impairment at follow-up. However, our follow-up duration did not extend into adulthood. Only 3 patients from included studies were followed up long term. Further studies are required to evaluate any longer-term effects on development. Some patients will inevitably require surgical evacuation of SDH. Notably, most of these patients had hydrocephalus, which likely contributed to further delayed deterioration and resulted in surgery [14]. In contrast, only one conservatively managed patient had hydrocephalus. This is consistent with our conservatively managed cases. Nonetheless, outcomes in the surgical cohort were still positive, with 57.1% achieving full resolution of symptoms and the remainder sustaining persistent neurological deficit or global developmental delay. This is likely indicative of more severe pre-existing brain damage within the surgical cohort. This highlights the importance of close monitoring and prompt neurosurgical intervention on clinical deterioration or development of alarming features such as hydrocephalus.

Acute deterioration following FAD in the presence of external signs of craniofacial injury may indicate underlying SDH. This requires prompt imaging and transfer to a Neurosurgical unit with maximal medical management and close monitoring for further deterioration. Conservative management is sufficient in over half of cases with successful outcomes. In some cases, typically involving hydrocephalus, neurosurgical intervention is required. Although outcomes are largely positive following surgery, a proportion may continue to have sustained neurological deficit.