Understanding Newborn Scalp Swelling:

Caput, Cephalohematoma, and Subgaleal Hemorrhage

Few things make a newborn exam more nerve-racking than finding a swollen, bruised scalp. Is it harmless? Or is it something serious?
Knowing the difference between caput succedaneum, cephalohematoma, and subgaleal hemorrhage is essential for every NICU and newborn nurse — because subtle changes can signal big physiologic shifts.

Caput Succedaneum: The Most Benign of the Three

What it is:
Caput succedaneum is edema of the scalp caused by pressure on the presenting part during vaginal delivery, especially in vertex presentations.

Pathophysiology:
The pressure from the cervix or vaginal walls impairs venous and lymphatic drainage, leading to superficial fluid accumulation in the subcutaneous layer above the periosteum.

Key features:

• Crosses suture lines (since it’s superficial)

• Soft, pitting edema, and sometimes bruising

• Usually resolves within 2–3 days

Because the swelling is purely edematous, it rarely causes complications — though it can contribute mildly to hyperbilirubinemia if significant bruising occurs.

💡 Quick Tip: If swelling crosses sutures and resolves quickly, think caput. If it’s firm and confined, think cephalohematoma.

Cephalohematoma:

A collection of blood

What it is:
A cephalohematoma is a collection of blood beneath the periosteum, confined by skull sutures. It often develops after mechanical trauma during delivery — such as vacuum or forceps use — and most commonly appears over one parietal bone.

Pathophysiology:
Rupture of blood vessels between the skull and periosteum causes localized bleeding, which the periosteum then traps, preventing the collection from crossing sutures.

Clinical findings:

• Firm, tense swelling that may enlarge in the first few days

• Typically limited to one bone (often unilateral parietal)

• No fluctuation or pitting

• No significant acute blood loss

Complications:

• Hyperbilirubinemia from RBC breakdown

• Late-onset anemia if the bleed is large

• Rare infection (osteomyelitis or meningitis)

Parental teaching:
Parents should know that the swelling may appear to increase initially but typically resolves over weeks to months as the blood reabsorbs.

Ensure parents know the signs that need medical review:

• Redness, warmth, or drainage

• Induration

• Fever or irritability

Sometimes, small calcified ridges remain temporarily after healing — these are benign and resolve with time.

Follow-up:
Babies with moderate to large cephalohematomas may need outpatient bilirubin and hematocrit monitoring, especially if jaundice or pallor develops.

🩺 If you love connecting pathophysiology to what you see at the bedside, subscribe to my free NICU newsletter — I share bite-sized education to strengthen your neonatal assessment skills. Join here →

Subgaleal Hemorrhage: A True Emergency

What it is:
A subgaleal hemorrhage occurs when blood collects in the space between the periosteum and the aponeurosis — a space that extends from the eyebrows to the nape of the neck.

Pathophysiology:
Traction and shearing forces during delivery (especially vacuum extraction) rupture emissary veins that bridge this large space. Unlike cephalohematoma, the bleeding is not confined by sutures — meaning a massive volume of blood can accumulate here.

Clinical signs:

• Diffuse, boggy swelling that crosses sutures and enlarges after birth

• Swelling may cause ears to push forward or eyelids to puff

• Pallor, hypotonia, tachycardia, and poor perfusion

• Increasing head circumference and delayed capillary refill

• Possible respiratory distress or hypovolemic shock

Monitoring priorities:

• Serial vital signs — watch for tachycardia and falling BP

• Head circumference measurements every few hours

• Frequent hematocrit and bilirubin levels

• Ongoing neurological assessment for lethargy or irritability

Interventions:

• Rapid recognition and treatment of shock (fluids, blood transfusion as needed)

• Close collaboration with neonatology and transport if the baby is in a community setting

• Strict documentation of trends in swelling, labs, and hemodynamics

Parental communication:
These cases can be frightening. Keep parents updated, explain the plan clearly, and prepare them for possible transfusion or intensive monitoring. Reassure them that recovery is possible with prompt treatment, though the swelling may persist for several weeks.

Bringing It All Together

Understanding these differences turns what could be a scary finding into a structured assessment. It’s not just about identifying swelling — it’s about anticipating complications, preventing shock, and supporting families through recovery.

🧠 Ready to deepen your neonatal assessment skills?

Join my Head-to-Toe Assessment Course for NICU Nurses, a 2-hour CE-accredited class that brings newborn physiology to life with photos, videos, and real case studies. Learn more here →

References

Gardner, S. L., Carter, B. S., Enzman-Hines, M. I., & Hernandez, J. A. (2021). Handbook of Neonatal Intensive Care: An Interprofessional Approach (9th ed.). Elsevier.

Verklan, M. T., & Walden, M. (2021). Core Curriculum for Neonatal Intensive Care Nursing (6th ed.). Elsevier.

Martin, R. J., Fanaroff, A. A., & Walsh, M. C. (2020). Fanaroff and Martin’s Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant (11th ed.). Elsevier.