Chignon (medical term)

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Chignon
Vacuum Extraction bruised scalp.JPG
A baby's scalp showing the effects of a vacuum extraction.
Specialty Pediatrics

A chignon (an artificially induced caput succedaneum) is a temporary swelling caused by a build-up of bloody fluid left on an infant's head after they have been delivered by vacuum extraction. A vacuum extraction is a type of assistance used during vaginal delivery by an obstetrician or midwife when the second stage of labor, where the cervix is fully dilated allowing for fetus delivery, is stalled. [1] [2] [3] [4] [5] It anatomically resembles regular caput succedaneum, one of two most frequently occurring birth injuries to the head, the other being cephalohematoma, a usually harmless condition where blood accumulates under the newborn's scalp after vaginal delivery. [6] [7]

Contents

During vacuum extraction, the cup is attached to the infant's head, exposing the infant to trauma due to the vacuum pressure and pulling force involved in the procedure. [6] This form of assisted delivery is typically required when the labor is stalled due to difficulties in the stages of labor arising, such as when the infant's head found too high in the birth canal. Due to prolonged pressure and tension, this induces an accumulation of interstitial fluid (the fluid that surrounds cells) as well as possible minor hemorrhages, ultimately resulting in scalp swelling. [8] [9]

A chignon should not be mistaken for bruises or other similar fetal head traumas relating to vacuum extraction. [10] It chignon should begin to resolve within an hour, but it may take between 12 and 18 hours to completely disappear. [11] [12] There are no long-term consequences for the newborn, but as with all birth traumas, it is recommended to be attended to and monitored. [6] [11]

Cause

When the vacuum is applied to the infant's head, the tension creates a difference in pressure between the atmosphere and the infant's scalp that causes the soft tissue layers of the scalp to fill inside the suction cup. [5] [6] Subsequently, interstitial fluid and small hemorrhages build up, causing the head to swell and forming a localized edema. [11] [5] [9] A chignon must be formed when performing a vacuum extraction with a hard plastic or metal cup in order to effectively adhere to the infant's head. [13] This occurs because a hard cup does not spread out over the head like a soft cup. [12] Because it takes a maximum of 2 minutes for a chignon to form, the vacuum extraction should be completed within 15 minutes in order to prevent injury to the baby. [13] A soft cup does not require a chignon to form and is associated with less trauma to the infant, despite a higher risk of cup detachment, which can lead to other injuries, such as lacerations to the scalp. [13]

Vacuum extraction of baby. Vacuum-assisted Delivery.png
Vacuum extraction of baby.

A chignon is firm and can cross suture lines, and it is often circular in appearance due to the shape of the suction cap. [11] [14] [15] The swelling may shift to each side depending on the position of the infant's head. [6]

Caput succedaneum

While a chignon and caput succedaneum are anatomically the same, a chignon is induced by the suction cup used during a vacuum extraction, while a true caput succedaneum is a natural buildup of fluid caused by the pressure induced when the infant's head passes through its mother's cervix. [5] [16] A chignon always involves a buildup of serosanguinous fluid, but a caput succedaneum can involve either serosanguineous or hemorrhagic fluid. [5] [16] Serosanguinous fluid is defined as fluid collected or leaving the body, containing both blood as well as the liquid portion of the blood (serum). [17]

Clinically, a caput succedaneum is soft and uneven, with a depth of about 1 to 2 cm. It can include petechiae, (small, pinpoint red or purple spots due to bleeding), purpura (a purple rash due to blood vessel leakage), and/or a bruised appearance. [6] [18] [19] Like a chignon, a caput succadaneum is usually benign and should resolve within a few days postpartum. [6]

Unlike a chignon, a caput succedaneum can lead to further complications, such as halo scalp ring, a form of hair loss or alopecia. [6] In some cases, a caput succadaneum can cause permanent hair loss or scarring. [6] Finally, jaundice is also a known possible complication of caput succedaneum. [16]

Subgaleal hemorrhage

Unlike a chignon with no long-term consequences, a subgaleal hemorrhage is a more severe instance of trauma associated with vacuum extraction and forceps delivery, however most commonly caused by vacuum extraction. A subgaleal hemorrhage is introduced into the loose connective tissue found within the subgaleal space, ultimately causing hypovolaemia. Hypovolemia is defined as a state of having a depleted circulating blood volume or fluids in the body. [20] This issue arises when the infant loses about 50-70% of the circulating blood volume, leading to complications such as hypovolemic shock, anemia, and coagulopathy. [21] While subgaleal hemorrhage is a rare complication, it is considered lethal. [9]

Clinical manifestations of a subgaleal hemorrhage are variable; it is recommended that the mean time for diagnosis is typically within 1–6 hours after birth, especially if the infant delivery was through vacuum delivery or prolonged due to complications. [22] Therefore, close monitoring of a newborn infant is prompted with a minimum of eight hour observation for all infants delivered by vacuum extractions or forceps deliveries. [11] A subgaleal hemorrhage may initially look like a caput succedaneum or a chignon because blood crosses the suture lines for all three conditions. [6] However, notifiable signs of a subgaleal hemorrhage include fluctuant scalp swelling, a lesion crossing the suture lines, pitting edema continuing over the head, and fluid wave test. [21]

If a subgaleal hemorrhage is suspected, measures such as hemoglobin count should be performed immediately and monitored every 4-8 hours. Also, imaging for subgaleal hemorrhage such as CT, MRI or radiographs of the skull can be done in order to identify any notifiable fractures. [21] [9] Through early recognition and careful monitoring, hypovolemic shock can be avoided. When any form of assisted delivery devices have been used during labor, the individual(s) caring for the child must be notified that the child must be regularly examined and monitored. By doing so, increasing awareness of chignons and subgaleal hemorrhages will lead to earlier identification, referral and treatment. [14] [11] [9]

Cephalohematoma

Chignon and cephalohematoma are both relatively common birth injuries which occur to the newborn's head during vacuum delivery. Cephalohematoma and chignon are considered to pose no long-term consequences on a newborn's health. [6]

A cephalohematoma which occurs in 0.4% to 2.5% of live births, is where pressure during vaginal delivery to the fetal head causes blood vessels rupture in the periosteum (a membrane layer covering bone exterior) leading to blood accumulation in the subperiosteal space, a space situated below the periosteum. [23] [24] While the chignon may cross suture lines, cranial sutures (strong tissue that is naturally found connecting the bones of the skull together) are the boundaries for cephalohematoma. [6] [22] [25] As the accumulation of blood into the subperiosteal space is relatively slow, unlike the chignon which immediately occurs upon use of vacuum extraction, cephalohematomas will arise during the first one to three days after birth. [23]

Cephalohematomas more frequently will occur during delivery of infants assigned male at birth compared to infants assigned female at birth, however the reasons are unknown. Some other common factors that can cause cephalohematoma are when using forceps or vacuum-assisted delivery methods, vaginal delivery of large infants, primigravida (the first pregnancy conceived by a pregnant person), when the infant is in a non-ideal position during delivery, and having a prolonged second stage of labor. [23]

Similar to chignon, treatment for cephalohematoma is not required as the body is expected to reabsorb the fluid accumulating in the subperiosteal space. Attempting to drain or aspirate the collected fluid may result in an infection and abscess formation, and is therefore not recommended. [23]

Optimization of vacuum-assisted delivery

Chignons are essentially both normal and harmless byproducts of vacuum-assisted delivery. In practically all cases, chignons disappear on their own within a couple of days postpartum and do not necessitate medical treatment. [6] However, as noted, chignons are not the only side effects induced by vacuum-assisted delivery; therefore, it is still necessary to keep an eye out during the healing process in the event of other possible complications. [6] [26] Prolonged vacuum traction, improper cup placement, and sudden cup detachment are all factors contributing to both maternal and neonatal complications that need to be considered when applying vacuum extraction. [26]

Despite the known risks of vacuum-assisted delivery, it nowadays tends to be a more commonly used birth-assisting tool due to its relatively lower occurrences of both maternal and neonatal complications compared to other methods, such as using forceps or a C-section, which tends to be a last resort option due to risks of significantly greater maternal morbidity. [3] [27] There have also been developed practices to minimize the impact of vacuum-assisted delivery on the neonatal head. Such a method is to use a proper vacuum cup to apply pressure up to 0.8 kg/cm2 and rhythmically sync the vacuum with uterine contractions in order to both expedite the delivery process and minimize traction-induced scalpel swelling. [26] The infant's head should be regularly checked throughout the hospital stay. [10]

It is crucial to know when to stop; the longer the delay, the higher the chance of both maternal and neonatal complications developing. [28] All in all, both communicating with and updating healthcare personnel are key; parents and caretakers are encouraged to immediately report any changes or signs of worsening complications. [6]

See also

Related Research Articles

<span class="mw-page-title-main">Childbirth</span> Conclusion of the human pregnancy with the expulsion of a fetus from mothers womb

Childbirth, also known as labour, parturition and delivery, is the completion of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million human births globally. In the developed countries, most deliveries occur in hospitals, while in the developing countries most are home births.

<span class="mw-page-title-main">Vacuum extraction</span> Method to assist the delivery of a baby

Vacuum extraction (VE), also known as ventouse, is a method to assist delivery of a baby using a vacuum device. It is used in the second stage of labor if it has not progressed adequately. It may be an alternative to a forceps delivery and caesarean section. It cannot be used when the baby is in the breech position or for premature births. The use of VE is generally safe, but it can occasionally have negative effects on either the mother or the child. The term ventouse comes from the French word for "suction cup".

A hysterotomy is an incision made in the uterus. This surgical incision is used in several medical procedures, including during termination of pregnancy in the second trimester and delivering the fetus during caesarean section. It is also used to gain access and perform surgery on a fetus during pregnancy to correct birth defects, and it is an option to achieve resuscitation if cardiac arrest occurs during pregnancy and it is necessary to remove the fetus from the uterus.

<span class="mw-page-title-main">Cephalohematoma</span> Bleeding between the skull and the periosteum tissue

A cephalohaematoma is a hemorrhage of blood between the skull and the periosteum at any age, including a newborn baby secondary to rupture of blood vessels crossing the periosteum. Because the swelling is subperiosteal, its boundaries are limited by the individual bones, in contrast to a caput succedaneum.

The emissary veins connect the extracranial venous system with the intracranial venous sinuses. They connect the veins outside the cranium to the venous sinuses inside the cranium. They drain from the scalp, through the skull, into the larger meningeal veins and dural venous sinuses. They may also connect to diploic veins within the skull.

<span class="mw-page-title-main">Subgaleal hemorrhage</span> Bleeding between the skull and fibrous tissue enclosing it

Subgaleal hemorrhage, also known as subgaleal hematoma, is bleeding in the potential space between the skull periosteum and the scalp galea aponeurosis.

<span class="mw-page-title-main">Caput succedaneum</span> Scalp swelling in newborns due to pressure during birth

Caput succedaneum is a neonatal condition involving a serosanguinous, subcutaneous, extra-periosteal fluid collection with poorly defined margins caused by the pressure of the presenting part of the scalp against the dilating cervix during delivery.

<span class="mw-page-title-main">Uterine atony</span> Loss of tone in the uterine musculature

Uterine atony is the failure of the uterus to contract adequately following delivery. Contraction of the uterine muscles during labor compresses the blood vessels and slows flow, which helps prevent hemorrhage and facilitates coagulation. Therefore, a lack of uterine muscle contraction can lead to an acute hemorrhage, as the vasculature is not being sufficiently compressed. Uterine atony is the most common cause of postpartum hemorrhage, which is an emergency and potential cause of fatality. Across the globe, postpartum hemorrhage is among the top five causes of maternal death. Recognition of the warning signs of uterine atony in the setting of extensive postpartum bleeding should initiate interventions aimed at regaining stable uterine contraction.

Neonatal alloimmune thrombocytopenia is a disease that affects babies in which the platelet count is decreased because the mother's immune system attacks her fetus' or newborn's platelets. A low platelet count increases the risk of bleeding in the fetus and newborn. If the bleeding occurs in the brain, there may be long-term effects.

<span class="mw-page-title-main">Obstetrical forceps</span> Medical instrument used for the delivery of a baby

Obstetrical forceps are a medical instrument used in childbirth. Their use can serve as an alternative to the ventouse method.

<span class="mw-page-title-main">Vaginal delivery</span> Delivery through the vagina

A vaginal delivery is the birth of offspring in mammals through the vagina. It is the most common method of childbirth worldwide. It is considered the preferred method of delivery, as it is correlated with lower morbidity and mortality than caesarean sections (C-sections), though it is not clear whether this is causal.

<span class="mw-page-title-main">Intraventricular hemorrhage</span> Bleeding into the brains ventricular system

Intraventricular hemorrhage (IVH), also known as intraventricular bleeding, is a bleeding into the brain's ventricular system, where the cerebrospinal fluid is produced and circulates through towards the subarachnoid space. It can result from physical trauma or from hemorrhagic stroke.

An asynclitic birth or asynclitism are terms used in obstetrics to refer to childbirth in which there is malposition of the head of the fetus in the uterus, relative to the birth canal. Asynclitic presentation is different from a shoulder presentation, in which the shoulder is presenting first. Many babies enter the pelvis in an asynclitic presentation, and most asynclitism corrects spontaneously as part of the normal birthing process.

<span class="mw-page-title-main">Birth trauma (physical)</span> Medical condition

Birth trauma refers to damage of the tissues and organs of a newly delivered child, often as a result of physical pressure or trauma during childbirth. It encompasses the long term consequences, often of cognitive nature, of damage to the brain or cranium. Medical study of birth trauma dates to the 16th century, and the morphological consequences of mishandled delivery are described in Renaissance-era medical literature. Birth injury occupies a unique area of concern and study in the medical canon. In ICD-10 "birth trauma" occupied 49 individual codes (P10–Р15).

<span class="mw-page-title-main">Circumvallate placenta</span> Medical condition

Circumvallate placenta is a rare condition affecting about 1-2% of pregnancies, in which the amnion and chorion fetal membranes essentially "double back" on the fetal side around the edges of the placenta. After delivery, a circumvallate placenta has a thick ring of membranes on its fetal surface. Circumvallate placenta is a placental morphological abnormality associated with increased fetal morbidity and mortality due to the restricted availability of nutrients and oxygen to the developing fetus.

Odón device is a medical device that is designed to assist during a difficult birth. The device consists of a plastic sleeve that is inflated around the baby's head and is used to gently pull and ease the head of the infant through the birth canal.

<span class="mw-page-title-main">Prolonged labor</span> Medical condition

Prolonged labor is the inability of a woman to proceed with childbirth upon going into labor. Prolonged labor typically lasts over 20 hours for first time mothers, and over 14 hours for women that have already had children. Failure to progress can take place during two different phases; the latent phase and active phase of labor. The latent phase of labor can be emotionally tiring and cause fatigue, but it typically does not result in further problems. The active phase of labor, on the other hand, if prolonged, can result in long term complications.

<span class="mw-page-title-main">Neonatal infection</span> Human disease

Neonatal infections are infections of the neonate (newborn) acquired during prenatal development or within the first four weeks of life. Neonatal infections may be contracted by mother to child transmission, in the birth canal during childbirth, or after birth. Neonatal infections may present soon after delivery, or take several weeks to show symptoms. Some neonatal infections such as HIV, hepatitis B, and malaria do not become apparent until much later. Signs and symptoms of infection may include respiratory distress, temperature instability, irritability, poor feeding, failure to thrive, persistent crying and skin rashes.

<span class="mw-page-title-main">Emergency childbirth</span>

Emergency childbirth is the precipitous birth of an infant in an unexpected setting. In planned childbirth, mothers choose the location and obstetric team ahead of time. Options range from delivering at home, at a hospital, a medical facility or a birthing center. Sometimes, birth can occur on the way to these facilities, without a healthcare team. The rates of unplanned childbirth are low. If the birth is imminent, emergency measures may be needed. Emergency services can be contacted for help in some countries.

<span class="mw-page-title-main">Operative vaginal delivery</span>

Operative vaginal delivery, also known as assisted or instrumental vaginal delivery, is a vaginal delivery that is assisted by the use of forceps or a vacuum extractor.

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Further reading