Reading Retinal Haemorrhage Patterns in Newborn Eye Exams

A healthy-looking newborn can still carry small but meaningful signs inside the eye, and recognising them early shapes the trajectory of care. Among the findings that clinicians look for during a neonatal ophthalmic screen, retinal haemorrhage sits at the crossroads of birth physiology, obstetric intervention, and rare but serious underlying disease. Getting the interpretation right protects the baby, reassures the family, and avoids unnecessary investigation.

Across Australian maternity units the newborn eye review has shifted from a quick torch-light glance to a more structured assessment, particularly after instrumental deliveries and prolonged second stages. This shift has been driven by clearer imaging, accessible tele-ophthalmology, and a stronger evidence base coming from groups such as the Australian and New Zealand Neonatal Network. The sections below walk through how to read what is seen, what to record, and when to escalate.

Why the Newborn Eye Exam Matters

The retina offers a window into both the birth process and the infant's broader physiology. In term babies, retinal haemorrhage is reported in roughly one in four to one in three vaginal deliveries, with much higher rates after ventouse or forceps assistance. Australian data published through collaborative registries suggests the incidence at tertiary centres in Sydney and Melbourne tracks international figures, while spontaneous onset after elective caesarean section remains rare. Understanding the pattern of bleeding helps clinicians separate expected bruising from signals that warrant further work-up, a theme echoed across the broader perinatal programmes shared at the FAOPS 2020 congress.

Perinatal services in Australia have moved toward standardised documentation. Many tertiary units in Brisbane, Perth, and Adelaide now include a retinal check in the early discharge pathway for infants born after assisted vaginal birth. The exam is brief, performed after pupillary dilation, and complements the universal newborn hearing and hip checks already in place. Recording whether the media are clear, the red reflex is present, and the retinal vasculature appears normal gives every clinician a clean baseline from which change can be measured.

Mechanisms Behind Neonatal Retinal Haemorrhage

The mechanism behind most birth-related retinal haemorrhage is sudden compression and decompression of the fetal head, producing pressure gradients across the immature retinal vessels. Vacuum extraction raises the risk substantially because the suction cup distorts the globe and increases venous pressure transiently. Forceps, precipitous labour, and a prolonged second stage all contribute. In contrast, infants born by elective caesarean section rarely show intraretinal bleeding, which is one of the most useful clinical clues at the cot side.

Beyond mechanical causes, the examiner should keep coagulopathies, thrombocytopenia, and severe perinatal asphyxia in mind. Newborns with early-onset sepsis or those whose mothers took medications affecting platelet function can also present with retinal bleeds. In extremely preterm infants, plus disease and aggressive retinopathy of prematurity can coexist with haemorrhage, changing the urgency of referral. Distinguishing the dominant mechanism shapes both prognosis and the parents' explanation.

Classifying Bleeds by Grade, Location, and Laterality

Severity is described along three axes: extent of the retina involved, depth within the retinal layers, and whether the macula is affected. Mild bleeds typically occupy less than a quadrant and spare the macula. Moderate bleeds cross multiple quadrants or involve the nerve fibre layer, while severe bleeds obscure the disc, the macula, or spill into the vitreous. Bilateral findings are common after instrumental birth and usually carry the same prognosis as unilateral bleeds of the same grade.

Location matters as much as quantity. Flame-shaped haemorrhages along the nerve fibre layer tend to resorb quickly, whereas deeper dot or blot haemorrhages can persist for weeks. Subretinal or preretinal bleeds, especially those that track toward the macula, are uncommon and deserve closer review. A practical grading framework used in many Australian units is shown below.

Distinguishing Birth-Related Bleeds from Underlying Pathology

The hardest interpretive call comes when a retinal haemorrhage does not fit the clinical story. A bleed appearing many days after birth, layered bleeds extending into the periphery, or retinal haemorrhage in an infant born by uncomplicated caesarean section should raise the index of suspicion. In Australian practice, the differential regularly includes non-accidental injury, neonatal alloimmune thrombocytopenia, vitamin K deficiency bleeding, and congenital infections such as cytomegalovirus.

A careful history helps anchor the interpretation. Asking about the mode of delivery, length of labour, use of instruments, and any maternal platelet or bleeding disorder gives context. Examination of the skin for petechiae, the umbilicus for bleeding, and the fontanelle for tension adds objective data. Where uncertainty persists, shared review with a paediatric ophthalmologist through a state-wide tele-ophthalmology network, such as those running out of the Royal Children's in Melbourne or the Children's Hospital at Westmead, shortens the path to a clear answer.

Documenting and Imaging Findings

Accurate documentation protects the baby and the team. Most Australian units now photograph the fundus with a wide-field digital system such as the RetCam or equivalent, allowing remote review. Images should capture the disc, the macula, and all four quadrants. A short structured note describing the grade, laterality, and location, alongside the time since birth and the mode of delivery, becomes the medico-legal anchor for any later discussion.

When wide-field imaging is not available, a clear hand-drawn retinal diagram remains acceptable, particularly in smaller regional hospitals. The key is consistency: each unit should agree on a grading template, document whether the haemorrhage has been reviewed by an ophthalmologist, and record the planned review interval. Photographs and notes should be stored in the infant's electronic record, accessible to the GP, the paediatrician, and the eye team involved.

Communicating with Parents and the Wider Team

Parents remember the words used during the first hours after birth. Australian clinicians often describe a small retinal bleed as a "tiny bruise inside the eye, similar to the marks on the scalp after a ventouse", which most families find reassuring. Clear language helps families understand why follow-up is scheduled and when the bleed is expected to resolve. Cultural safety matters too; Aboriginal and Torres Strait Islander families, and those from culturally diverse backgrounds in suburbs like Parramatta or Dandenong, benefit from interpreters and written information in their preferred language.

Communication across disciplines needs the same care. A short summary shared with the GP, the maternal child health nurse, and the paediatric team keeps the review pathway visible. Where bleeding is unexplained or severe, escalation to social work and child protection services follows a documented protocol, guided by state health guidelines. The exam and its documentation are not a substitute for those systems, but they strengthen them.

Follow-Up Pathways in Australian Practice

Most birth-related retinal haemorrhages resorb without intervention. A pragmatic schedule in many Australian units reviews mild bleeds at the routine six-week check, moderate bleeds within two to four weeks, and severe bleeds or those involving the macula within one to two weeks. Tele-ophthalmology referrals through Queensland's outreach service or NSW's rural paediatric network allow families in places like Dubbo or Broome to be reviewed without travelling to a capital city.

Where a bleed is flagged as suspicious, the next steps include paediatric ophthalmology review, coagulation studies, cranial imaging, and a safeguarding discussion. The pathway varies between states but the principle is consistent: early review, clear documentation, and a named clinician responsible for closing the loop. Education for junior medical officers and midwives about the red flags keeps the system responsive.

The science of reading retinal haemorrhage in newborns keeps maturing, with better imaging, broader tele-ophthalmology access, and more consistent Australian data shaping everyday practice. Clinicians who approach each exam with a structured grading, a clear differential, and a respectful conversation with the family tend to make the cleanest calls. Take the topic into the next unit teaching round, pair it with the surfactant therapy review hosted on the same site, and turn a quick bedside glance into a structured part of newborn care across your service.