One relatively common complication of childbirth is a 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 severity and location of the brain bleed determine how serious the injury might be.
The words “newborn brain bleed” are understandably frightening for the parents. In practice, a brain bleed can range from insignificant to life-threatening.
A brain bleed occurs for different reasons. Premature babies are much more likely to develop this condition, and this is related to the immaturity of their circulation. But a brain bleed can also happen to term delivery newborns.
Surgically assisted deliveries – primarily a vacuum or forceps – increase the risk of a brain bleed. 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, to say the least, if both vacuum and forceps are used (it is almost inevitably medical malpractice if both 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 there is head swelling, the doctor will examine the baby and watch for worsening of the swelling and for other symptoms.
Most newborns with a brain bleed have some swelling of the scalp. Swelling does not mean the injury involves a significant brain bleed. Two other conditions also involve scalp swelling – caput succedaneum and cephalohematoma – that are usually benign.
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 typically 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. In these cases, the newborn will be transferred to the Neonatal Intensive Care Unit for more testing and treatment.
A cranial head ultrasound can often access the severity of a brain bleed. 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 neonatal intracranial hemorrhage. 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.
Reducing preterm births can prevent many cases of infant brain bleeds. The best way to prevent preterm births is 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.
Finally, it cannot be ignored that many newborn brain bleeds are the result of poor choices made by doctors and nurses during childbirth.
According to a large case study, the use of vacuum-assisted deliveries did not increase the risk of long-term consequences for babies with ICH. In short, the babies most affected by ICH appeared to recover. This is good news.
But 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. Speak up if you have concerns about the child’s development or behavior.
Åberg, Katarina, et al.: “Protracted vacuum extraction and neonatal intracranial hemorrhage among infants born at term: a nationwide case‐control study.” Acta Obstetricia et Gynecologica Scandinavica 98.4 (2019): 523-532. (This study sought to find an association between protracted vacuum-extracted deliveries and intracranial hemorrhaging. The researcher’s data included vacuum-extracted Swedish infants who were diagnosed with a brain bleed. They compared these infants to three vacuum-delivered deliveries with no brain bleed diagnosis. The researchers found that infants who underwent a protracted extraction were nine times more likely to suffer a brain bleed. They concluded that following vacuum-extraction safety recommendations might reduce the brain bleed risk.)
Andersson, Nadine G., et al.: “Mode of delivery in hemophilia: Vaginal delivery and Cesarean section carry similar risks for intracranial hemorrhages and other major bleeds.” Haematologica 104.10 (2019): 2100. (This study sought to determine the brain bleed rate between Hemophilia carrier mothers who underwent a vaginal delivery and those who underwent a C-section. The researchers found that 2.4 percent of vaginally-delivered infants suffered brain bleeds compared to 1.7 of those who were delivered via C-section. They concluded that vaginal deliveries and C-sections carried similar brain bleed risks in Hemophilia carrier mothers
Cashen, Katherine, et al.: “Is therapeutic hypothermia during neonatal extracorporeal membrane oxygenation associated with intracranial hemorrhage?” Perfusion 33.5 (2018): 354-362. (This study looked at the therapeutic hypothermia’s effect on infants undergoing extracorporeal membrane oxygenation. They found that infants who underwent therapeutic hypothermia were more likely to suffer a brain bleed during the first week of ECMO compared to infants who did not.)
Lakatos, Andrea, et al.: “Neurodevelopmental effect of intracranial hemorrhage observed in hypoxic ischemic brain injury in hypothermia-treated asphyxiated neonates-an MRI study.” BMC Pediatrics 19.1 (2019): 1-11. (This study sought to find whether the presence of brain bleeds and hypoxic-ischemic encephalopathy impact the prognosis in HIE-diagnosed infants. The researchers’ data comprised 108 term infants with asphyxia who underwent whole-body hypothermia. They found that 72 percent of infants with brain bleeds showed HIE signs in their MRI and MR-spectroscopy results. The researchers concluded that HIE signs in the MRI of infants who underwent whole-body hypothermia helped determine poor outcome prognosis.)
Sanapo, Laura, et al.: “Fetal intracranial hemorrhage: role of fetal MRI.” Prenatal Diagnosis 37.8 (2017): 827-836. (This study looked at the role of MRIs in diagnosing fetal brain bleeds and characterizing the condition’s topography. They examined MRI-diagnosed fetal brain bleed cases between 2008 and 2015. The researchers found that over 86 percent of MRIs were performed because the ultrasound detected an unknown cerebral anomaly. They also found that the MRIs were able to distinguish between germinal matrix hemorrhages and non-GMH hemorrhages. The researchers concluded that MRIs help diagnose prenatal brain bleeds by detecting intracranial abnormalities that ultrasounds cannot detect.)