11.5 Cranial Assessment & Head-to-Chest Examination

Cranial Assessment & Differential Diagnosis of Scalp Swellings

Cranial evaluation requires systematic palpation of fontanelles, suture lines, and scalp contours. The certified nurse-midwife must differentiate benign birth-related molding from life-threatening subaponeurotic hemorrhage.

Fontanelles & Sutures

• Anterior Fontanelle: Diamond-shaped, measuring 2 to 5 cm in diameter, located at the junction of the sagittal, coronal, and frontal sutures. Closes between 12 and 18 months of life. Should be soft, flat, and gently pulsatile. A bulging, tense fontanelle indicates elevated intracranial pressure (meningitis, hydrocephalus, hemorrhage); a sunken fontanelle indicates dehydration.
• Posterior Fontanelle: Triangular, measuring <1 cm (or fingertip size), located at the junction of the sagittal and lambdoid sutures. Closes early, between 2 and 3 months of life.
• Sutures & Molding: The sagittal, coronal, lambdoid, and metopic sutures should be palpated. Overriding sutures and elongated cranial molding are benign consequences of vertex passage through the birth canal and resolve spontaneously within 48 to 72 hours.
• Craniosynostosis: Premature pathologic fusion of one or more cranial sutures, producing an asymmetrical or abnormally shaped skull (e.g., scaphocephaly) and an immobile, ridged suture line. Warrants pediatric neurosurgical referral.

Differential Diagnosis of Perinatal Cranial Swellings

The table below outlines the classic clinical distinctions among cranial swellings—a frequent focus of high-stakes examination questions.

Systematic Organ System Examination: Head, Neck & Chest

Face, Eyes, Ears & Neck

• Eyes:
  • The Red Reflex: Elicited using a direct ophthalmoscope held 12 to 18 inches away. A normal reflex manifests as an equal, round, bright orange-red light reflected from both retinas. An abnormal reflex (white pupillary reflex or leukocoria) indicates congenital cataracts, retinoblastoma, or chorioretinitis, requiring immediate pediatric ophthalmology referral.
  • Subconjunctival Hemorrhage: Scleral bright-red crescentic extravasations caused by increased intrathoracic pressure during delivery. Completely benign; resolves spontaneously in 1 to 2 weeks.
  • Chemical Conjunctivitis: Mild bilateral conjunctival erythema appearing within 24 hours of prophylactic erythromycin administration; self-limiting within 24 to 48 hours.
• Ears: Assess shape, cartilage firmness, and position. Normal ear alignment: an imaginary horizontal line drawn from the outer canthus of the eye must intersect the upper helix of the pinna. Low-set ears (helix falls below the canthal line) correlate with genetic syndromes (Trisomy 21, Trisomy 18) and renal anomalies. Preauricular pits or skin tags are usually isolated benign findings, but when accompanied by family history or dysmorphic features, warrant renal ultrasonography due to shared embryological timing.
• Mouth & Palate: Inspect and digitally palpate the hard and soft palates with a gloved finger to exclude submucosal or complete cleft palate. Epstein pearls (small, firm, white inclusion cysts along the median raphe of the palate) are benign keratin deposits that resolve spontaneously. Inspect the frenulum for ankyloglossia (tongue-tie) if latch issues occur.
• Neck & Clavicles: Palpate both clavicles along their entire length. Focal tenderness, crepitus, bony irregularity, or asymmetric arm movement suggests a clavicular fracture (most common birth fracture, seen with shoulder dystocia). Assess the sternocleidomastoid muscle for hematomas (congenital torticollis) and inspect for redundant skin webbing (Turner syndrome).

Cardiorespiratory System

• Respiratory Assessment: Assess respiratory symmetry, chest expansion, and breath sounds bilaterally. Respiratory distress signs (grunting, tachypnea >60 bpm, intercostal/subcostal retractions, stridor) indicate conditions such as TTN, respiratory distress syndrome (RDS), or meconium aspiration syndrome (MAS).
• Cardiac Auscultation & Murmurs: Transient, soft systolic murmurs (Grade I–II/VI) auscultated in the first 24 to 48 hours are common and benign, typically representing delayed functional closure of the ductus arteriosus or peripheral pulmonary stenosis. However, any murmur accompanied by central cyanosis, abnormal pulses, or cardiogenic shock warrants immediate echocardiographic evaluation.
• Peripheral Pulses: Simultaneously palpate radial and femoral pulses. Diminished, weak, or delayed femoral pulses relative to upper extremity pulses strongly indicate Coarctation of the Aorta.

Abdomen & Umbilical Cord

• Contour: Normal abdomen is cylindrical, soft, and slightly protuberant. A scaphoid (sunken) abdomen strongly suggests Congenital Diaphragmatic Hernia (CDH), where abdominal viscera herniate into the hemithorax, accompanied by severe respiratory distress and dextroposition of heart sounds. Distention indicates bowel obstruction, Hirschsprung disease, or peritonitis.
• Organomegaly: The liver edge is normally palpable 1 to 2 cm below the right costal margin. The spleen tip is occasionally palpable (<1 cm below left costal margin in 10% of normal neonates). Kidneys are palpated bilaterally using deep bimanual technique immediately after birth when abdominal muscles are relaxed.
• Umbilical Cord Vessels: Inspect the freshly cut cord surface. A normal cord contains 3 vessels: two thick-walled muscular umbilical arteries and one larger, thin-walled umbilical vein (2A + 1V). A Single Umbilical Artery (SUA / two-vessel cord) occurs in ~1% of births; while often an isolated benign finding, it is associated with congenital renal and cardiovascular malformations, warranting thorough anatomical survey and renal ultrasonography if other abnormalities or growth restriction are present.