S.A. BUTLER-MANUEL, CATHERINE MORLEY-JACOBS and KAREN E. MORTON
The Royal Surrey County Hospital, Guildford, Surrey, UK
A healthy 19-year-old primigravida was admitted in early spontaneous labour at 40 weeks and 3 days gestation following an uncomplicated antenatal course. All observations on admission including the cardiotocograph (CTG) were normal. The uterus was contracting mildly, once every 5 minutes and vaginal examination revealed the cervix to be closed. She was admitted to the antenatal ward initially and subsequently progressed into active labour. An epidural was sited for analgesia and continuous monitoring was commenced. The CTG was normal during the first stage and labour was not augmented since contractions and progress were satisfactory. The first stage lasted 11 hours, the second stage 2 hours l6 minutes, and the third stage 12 minutes. Forty minutes were allowed in the second stage for descent of the head to occur, before commencing active pushing. Marked caput was noted by the midwife at confirmation of full dilatation by vaginal examination. Early decelerations were present on the CTG throughout the second stage, but late decelerations occurred during active pushing. Following delivery of the fetal head restitution was slow. The umbilical cord was tightly around the neck requiring it to be cut before delivery of the shoulders. An otherwise entirely normal vaginal delivery was achieved, with an intact perineum, of a male infant, weighing 3.55 kg. The baby was asphyxiated at birth, but responded to stimulation and oxygen via a bag and mask, and was given an Apgar score of 3 at 1 minute, 6 at 3 minutes, and 9 at 5 minutes. The baby underwent a full general examination at 18 hours of age. All appeared normal other than marked moulding of the head with no signs of neurological abnormality. The baby was successfully breast fed, but at approximately 56 hours of age, 2 hours after his last feed, the baby was found to be cold and lifeless and failed to respond to resuscitation.
Erect lateral pelvimetry of the mother revealed a normal 5 segment sacrum with AP inlet of 11.6 cm and AP outlet of 11.5 cm. Maternal haematological investigations including clotting screen, glycosylated haemoglobin and viral screen all proved normal. Post-mortem examination of the baby confirmed marked elongation of the fetal skull, consistent with marked moulding but no fracture was present. There was a moderate subdural haemorrhage in the posterior fossa extending up above the tentorium cerebelli, with a small tear on the left side with haemorrhage into its free borders. The findings were consistent with respiratory failure secondary to a posterior fossa subdural haemorrhage. There were no other abnormalities found to account for the baby's death.
This woman had a normal vaginal delivery, but may in other hands have been delivered by forceps or by ventouse extraction because of the CTG abnormality. Prenatal subdural haematoma (SDH) without a history of maternal trauma is extremely rare, but occult haemorrhage may occur before labour, notably with haemophilia, factor X deficiency or osteogenesis imperfecta, and has been detected antenatally using ultrasound and magnetic resonance imaging (Sohda et al., 1996). Neonatal SDH may present as a late manifestation of vitamin K deficiency, underlining the importance of routine vitamin K prophylaxis for all deliveries (Ries et al., 1993).
The majority of neonatal subdural haemorrhages are associated with traumatic delivery, in particular with the use of obstetric forceps, or ventouse extraction (O'Driscoll et al.. 1981; Lahat et al., 1987). This case demonstrates that SDH may occur in cases of spontaneous normal vaginal delivery, and that such injuries may not be the fault of obstetric intervention.
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