Nursing care
Vacuum-assisted birth: cephalohaematoma, subgaleal haemorrhage and maternal care
Written and reviewed by Dana Whitfield, RN, MSN · 4 min read · Updated October 2026
Short answer
After vacuum birth, a cephalohaematoma is a firm swelling limited to one skull bone that rarely threatens the baby, while a subgaleal haemorrhage is a boggy swelling that crosses sutures and can cause hypovolaemic shock within hours. The nurse monitors the newborn's head, colour and vital signs, and monitors the mother for perineal trauma and bleeding.
Why vacuum is used and the prerequisites
Vacuum extraction may shorten the second stage when labour is prolonged, when the fetal heart rate pattern is concerning, or when pushing is unsafe or ineffective because of maternal illness or exhaustion. Prerequisites include full cervical dilation, an engaged head at a low station, ruptured membranes, known fetal position, an empty bladder, consent and adequate analgesia.
Vacuum is avoided before 34 weeks because of increased intraventricular haemorrhage risk, and with known fetal bleeding disorders. The nurse helps prepare equipment, empties the bladder if directed, documents the timing and number of pulls described by the provider, and makes sure the neonatal team has been alerted.
Telling cephalohaematoma from subgaleal haemorrhage
A cephalohaematoma is bleeding beneath the periosteum, so it stops at the suture lines and stays over a single bone. It usually appears over the first few days, is generally benign and resolves over weeks. Because the blood is broken down, it can contribute to jaundice and occasionally anaemia, so bilirubin monitoring matters.
A subgaleal haemorrhage lies between the galea aponeurosis and the periosteum, a large potential space where enough blood can collect to cause shock. The swelling is boggy, crosses sutures and may extend to the forehead, ears or neck, typically within the first hours. Shock can develop before the full extent is obvious, so pallor, tachycardia, poor perfusion or increasing head size need emergency escalation.
Newborn monitoring after vacuum birth
Assess the scalp at birth and repeatedly over the first hours, noting the location, consistency and whether swelling crosses sutures. Serial head circumference measurements can show expanding bleeding. Monitor heart rate, respiratory rate, colour, capillary refill, tone and feeding, and report a falling haematocrit or haemoglobin. Use the same landmarks each time so measurements can be compared reliably across shifts.
Caput succedaneum, a soft scalp swelling that also crosses sutures, is common after any vaginal birth and is present from delivery, while a vacuum cup can leave a temporary circular swelling. Distinguish these from subgaleal haemorrhage by timing, progression and the baby's condition. Retinal bleeding and jaundice are also more common after vacuum birth.
Maternal complications and a hypothetical priority question
Operative vaginal birth increases the risk of perineal trauma, including third and fourth degree lacerations, and of postpartum haemorrhage. Monitor fundal tone, lochia, perineal swelling or haematoma, pain and voiding, and check that the bladder empties. Severe perineal pain with a swelling that keeps enlarging suggests a haematoma.
Consider a hypothetical newborn four hours after vacuum birth with a boggy scalp swelling extending to the ears, heart rate rising and pale skin. Options include applying cold to the swelling, rechecking in an hour, documenting a cephalohaematoma, or notifying the neonatal provider immediately. Immediate notification is correct because these findings fit subgaleal haemorrhage with developing shock. Cold packs and delayed review are the tempting distractors because they would suit a minor bruise, and calling it a cephalohaematoma ignores both the suture crossing and the vital sign change.
Documentation, handover and parent teaching
Record the indication, the time the cup was applied and removed, and the provider's description of the procedure, alongside the newborn's condition at birth and the initial scalp findings. A clear baseline description of any swelling allows the next nurse to judge whether it is growing or spreading. Hand over to the postnatal and neonatal teams that the birth was vacuum assisted.
Explain to parents that cup marks and caput usually settle within days and that a cephalohaematoma may take weeks to resolve and can feel firm as it heals. Teach them to report yellowing skin, poor feeding, unusual sleepiness, pallor or a head swelling that gets bigger. For the mother, explain perineal care, pain relief, bladder emptying and when bleeding is heavier than expected.
Sources and further reading
MSD Manual Professional: Operative vaginal delivery. Indications, prerequisites, contraindication under 34 weeks, neonatal cephalohaematoma, jaundice and retinal bleeding, and maternal lacerations and haemorrhage.
MSD Manual Professional: Birth injuries. Distinguishing caput succedaneum, cephalohaematoma and subgaleal haemorrhage by location, suture lines and timing, subgaleal onset in the first hours and haemorrhagic shock risk.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our maternity and newborn practice questions are the closest set to what this page covers.
Common questions
Does a cephalohaematoma cross suture lines?
No. It is limited to one bone because the periosteum attaches at the sutures. A swelling that crosses sutures suggests caput succedaneum or subgaleal haemorrhage.
Why is subgaleal haemorrhage dangerous?
The subgaleal space can hold a large volume of blood, so hypovolaemic shock may develop within hours, sometimes before the swelling looks severe.
What maternal complications follow vacuum birth?
Perineal trauma, including severe lacerations, and postpartum haemorrhage. Monitor fundal tone, bleeding, perineal swelling and voiding.