The high incidence of subdural hematoma (SDH) from birthing was first identified with MRI by Looney in 2007 and was then more accurately determined by Rooks in 2008. Rooks screened 101 "normal" deliveries and demonstrated that 46% of the babies in her series and by inference, approximately 46% of the 4 million born normally in the US have SDH that formed in the perinatal (birthing) period during labor. Both metabolic strain and physical forces exerted on the head damage the capillaries within the dura (the intradural capillary bed), which is the source of the blood in the SDH that results from labor and delivery or at times from labor alone. While child abuse pediatricians relying on Rooks, maintain that no permanent complications result, her study was limited to 101 subjects and the sole criteria for resolution was the resolution of the SDH as seen on follow-up MRI. In fact, Rooks did have one patient (1%) who had complications that lead to symptoms and findings often associated with abuse. The purpose of this article is to explore if there is a complication rate for perinatal (PSDH) that supports that 1% of complications that are definable by different criteria. Next, if there are complications, how many of the roughly 2,000,000 cases of perinatal acute subdural hematoma every year in the United States will suffer them? Then, what are the clinical manifestations of the complications if they occur? Lastly, do the complications cause or mimic some or all of the findings that are offered by board certified child abuse pediatricians as evidence of child abuse? The article argues that a small percentage, but significant number of neonates, suffer birth related complications and findings secondary to the development of chronic subdural hematoma CSDH) that are often misdiagnosed as abusive head trauma.

Aim Benign external hydrocephalus (BEH), hygroma and chronic subdural haematoma are extra‐axial fluid collections in infants. MRI studies have shown that almost half of all new‐borns have perinatal subdural blood, generally referred to as subdural haematoma (SDH) or perinatal SDH. Epidemiologically there are striking similarities between chronic SDH and BEH in infants. Methods Discussion of pathophysiological mechanisms for BEH and chronic SDH, based on existing literature. Results Perinatal SDH is common, and we hypothesise that this condition in some infants develop into extra‐axial fluid collections, known as hygroma, BEH or chronic subdural haematoma. The mechanism seems to be an intradural bleeding that creates an obstructive layer preventing normal CSF absorption. The site where the bleeding originates from and those areas enveloped in blood from the primary damaged area are prone to later rebleeds, seen as ‘acute on chronic’ haematomas. With steady production of CSF and the blockage, increased intracranial pressure drives the accelerated skull growth seen in many of these children. Conclusion Perinatal SDH hampers CSF absorption, possibly leading to BEH and chronic SDH, with a high risk of false accusations of abuse. Close monitoring of head circumference could prove vital in detecting children with this condition.

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