This case illustrates the importance of taking escalating risks seriously and emphasizes the value of early communication among healthcare providers.
An infant was delivered vaginally at 36 weeks by vacuum assist after one pull, with no pop-offs. The infant's head had an abrasion along the vacuum line on the scalp along with caput succedaneum, swelling of the scalp. The infant's head appeared diffusely swollen.
The baby was admitted to the neonatal intensive care unit (NICU) under the care of a neonatologist. The patient was mottled, pale, and hypotonic with a low hemoglobin of 10.8 g/dL (normal range, 15-20 g/dL). The physician suspected fetal maternal transfusion (had a positive antibody) but also had a differential diagnosis of a subgaleal (between the skin on the scalp and the skull) hemorrhage and suggested a blood transfusion. The parents refused the blood transfusion for religious reasons.
The physician ordered an antibiotic and an ultrasound for the following morning. He planned to check the baby's hemoglobin the next morning.
In the afternoon, the nurses recorded the gradually increasing swelling of scalp. They were unable to palpate sutures due to edema. The baby's blood pressure was normal. During the night, nurses noted abnormal movements along with increasing head circumference and swelling of scalp.
