Neonatal Intracranial Hemorrhage - Brain Bleeds During and After Childbirth

NewbornNo expectant mom plans for a major complication when she checks into the hospital. But when the delivery is prolonged or difficult, doctors must intervene. Parents should be aware of possible complications when this happens.

One complication is the neonatal brain bleed. This occurs when blood vessels break and bleed into the brain tissue itself. It is also called intracranial hemorrhage (ICH) or intraventricular hemorrhage (IVH). The danger to the baby is determined by how severe the bleed is.

When the words "brain bleed" are applied to a new baby, it is very frightening for the parents. To understand what it means, the process of a newborn ICH needs to be explained.

Why Does Intracranial Hemorrhage Happen?

An ICH can occur for different reasons. Premature babies are much more likely to develop this condition, and this is related to the immaturity of their circulation. Therefore, forceps are safer than vacuum assist for preterm deliveries. However, a brain bleed can also happen to term delivery newborns.

According to one study, when the delivery is assisted by vacuum or forceps, the risk of a serious newborn complication is 5%. The risk of complications becomes greater if both vacuum and forceps are used.

The pediatrician should be notified for any delivery when vacuum or forceps is used. The baby cannot be immediately discharged from the hospital, even if this is what the parents want. Instead, the baby will be checked for at least 10 hours to assess any head swelling, and the head circumference will be taken. If head swelling is noted, the doctor will examine the baby and watch for worsening of the swelling and for other symptoms.

What Does it Look Like?

Symptoms are not the same for every baby, but there is often some swelling of the scalp. This does not necessarily mean the injury involves a brain bleed. Two other conditions also involve scalp swelling: caput succedaneum and cephalohematoma.

In caput succedaneum, the swelling does not happen from bleeding under the scalp, but from bruising. The cause is the pressure on the baby's crown as she is pushed through the birth canal. The swelling can be increased when vacuum or forceps is used, but caput will decrease without medical intervention.

A cephalohematoma is caused by bleeding between the skin and the skull, but it also does not harm the brain. Like caput, it can happen without forceps or vacuum, but it is often associated with them. After the doctor examines the baby, performs further testing, and rules out a brain bleed, no further medical care is usually needed. A cephalohematoma can heal on its own.

With ICH, the swelling may be worse when a vacuum is used, as compared to forceps. If ICH becomes worse, he or she may have poor feeding, a high-pitched cry, or a have a bluish color around the mouth or on the nail beds. A long pause in breathing (apnea) can happen, or the baby can have seizures. At this point, the baby will be transferred to the Neonatal Intensive Care Unit. He or she will be closely monitored, and more testing will be performed.

To find out how severe the brain bleed has become, a cranial head ultrasound will be done. An ultrasound is preferred to other scans, because it does not expose the baby to ionizing radiation. After the ultrasound, the doctor can see how far the bleed has progressed into the brain, and the bleed can then be "graded."

Infant brain bleeds are classified according to grades (levels). In grades 1 and 2, the bleed is minor and does not affect the ventricles of the brain. The ventricles produce cerebrospinal fluid, and blood should never mix with this fluid. However, if the swelling is severe, there is concern that the ventricles will become swollen or brain tissue will be damaged. A grade of 3 or 4 will be diagnosed.

Surgery may be needed in the most severe incidents of ICH. Medications are given for other symptoms (like seizures). When ICH is a risk because of premature delivery, the mother can be given steroids to decrease the risk of ICH in the baby.

Can ICH be Prevented?

Reducing preterm births can prevent many cases of ICH. And the best way to prevent preterm births is through adequate prenatal care. Women who cannot afford prenatal care need to contact their nearest health department for information about low-cost prenatal care clinics.

But sometimes there is no prevention. If an expectant mother has a small build, and her baby is measured to be larger than usual, she may have difficulty with a normal delivery. She can request a Cesarean section in this situation, and her doctor may agree with her.

If the doctor or midwife must use a vacuum or forceps in the delivery, a Cesarean section must be considered. A C-section does not completely rule out the possibility of newborn ICH, but the risk can be reduced. The parents have a right to ask questions, especially during a difficult childbirth. The doctor needs to know if the mother wants to go forward with an assisted delivery.

How Will ICH Affect the Baby?

Mother and ChildAccording to a large case study in 2009, the use of vacuum-assisted deliveries did not increase the risk of long-term consequences for babies with ICH. In short, the babies affected by ICH appeared to recover. This is good news. However, the study also noted that some cases of ICH in infants had no symptoms. The diagnosis in those specific cases was discovered only by an MRI scan-which was done as part of routine orders after a failed vacuum attempt. There are also studies and pediatricians and gynecologists

When ICH is severe, brain tissue can be affected. Parents need to remember this, even if the baby does well after the swelling decreases. The degree of ICH should be noted in the baby's chart, and regular follow-up appointments with the doctor should be kept. Parents are the best advocate for their child, and they must speak up if they have concerns about the child's development or behavior.