When assessing an infant which of the would the midwife expect from a 4 month old baby?

In this demonstration video, Dr Elizabeth Forster explains what to be aware of when assessing the head and scalp of the newborn.

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Normally, your baby will be well wrapped and that’s because they have not very good thermoregulation, or maintenance of a good core body temperature. So, it’s a good idea to perform that assessment in a place where the baby’s going to be well wrapped and warm, because you want them to be comfortable and relaxed during the assessment. But for the examination of the head, you’ll need to of course, remove their little cap that they have. And then you’re wanting to actually inspect the baby’s head and just look at the shape of the baby’s head. During delivery, there can be some moulding of the baby’s head because of delivery. And that will normally normalise over the next few days after birth.

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But you need to, as well as inspecting the scalp, you need to actually palpate the scalp, or feel the scalp, just to make sure that there’s no areas of bogginess, or oedema, or fluid collection. There are some abnormalities that are quite serious. If there’s bleeding in the scalp, so if it feels boggy and that fluid that you can feel is moving across the cranial sutures, then that needs to be reported to the paediatrician and some intervention may be needed very quickly to avoid any complications there. So in terms of the scalp, you’ll be looking at the fontanelles. And there are four fontanelles.

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The main two are the anterior fontanelle, which you can palpate, or feel, at the top of the baby’s head, and that is diamond shaped. And then there’s a posterior fontanelle at the rear of the baby’s head, which is triangular shaped. Sometimes, the posterior fontanelle will be closed at birth. The anterior fontanelle will normally stay palpable and open, sometimes up to 12 to 18 months of age. So the fontanelle will normally be flat and it can be pulsatile, so you can actually see some pulsations in the normal fontanelle. It shouldn’t be sunken. If it’s sunken, that might indicate a hydration issue with the baby.

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And it shouldn’t be bulging either, because that might indicate a raised intra cranial pressure or some issue that’s causing fluid in the cranial cavity. So it should be, as I said, flat and pulsatile. There are two other ones, a mastoid suture fontanelle and also the sphenoid fontanelle. But the main two that we look at are the anterior and the posterior fontanelle. The next area that you’ll be looking at is the hair of the baby. And you just need to check that the hair may be– there may be plentiful hair in some babies, there may be only slight amounts of hair.

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One thing you do look for is a low hairline, because that can be associated with some syndromes in the neonate. So if a baby, for example, has a low hairline, and then doesn’t have very good tone in their body, that might indicate a problem that needs to be looked at. So now we’re going to assess the baby’s head circumference. And this is important as head circumference gives us an indication of brain growth. And so we need a baseline to start with with the neonate. And then the baby’s head circumference, as well as weight and length will be regularly measured as they grow in that first year of life.

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So, to measure the baby’s head circumference, what we want to do is actually make sure that the tape measure is above the baby’s eyebrows, over the pinna of the ear, and then round to the occiput, which is the broadest part of the base of the skull. And that’s the correct spot to actually do your measure. Usually, you’ll use a paper tape measure. It gives you much more flexibility than some of the plastic tape measures. And the normal head circumference for a term baby is 31 to 38 centimetres in length. So if you were to find that a baby’s head circumference was particularly large, or particularly small, those would be things that you would need to report on.

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And it may not indicate an issue. For example, genetics has a part to play in head size, et cetera. But if there was a particularly small head circumference, that might indicate an underlying problem and so would a large one, as well. So we just need to note that and then monitor. So it’s one part of your assessment. You’re looking at the overall baby, as well.

In a head to toe assessment, it makes sense to begin with an examination of the baby’s skull. Let’s explore what to note during your examination.

Our first step is to look and take note of the size of the skull. Keep in mind, the baby’s genetics, ethnic group, gestational age and growth in the womb will all play a factor in determining skull size (Kain & Mannix, 2018). The normal range for head circumference in a term baby is between 31 and 38cms.

The next area to assess is the scalp and fontanelles. The fontanelles are small spaces in between the ‘plates’ of the skull. These spaces are joined by cranial sutures and make it possible for the soft bones of the baby’s skull to move slightly, allowing easier passage through the birth canal.

The four fontanelles

The posterior fontanelle usually closes by around two to four months of age, however the anterior fontanelle may still be felt up until 18 months to 2 years of age (Forster & Marron, 2018). The sphenoid fontanelle is found on the side of the baby’s head a short distance behind the eye and the mastoid fontanelle is located behind the baby’s ear.

When assessing the fontanelles, use the flat pads of your fingers to palpate (gently feel) the surface of the head. Ensure you make note of any retraction or bulging, as the normal fontanelle feels firm and flat (not sunken or bulging). You may also notice visible pulsations in the anterior fontanelle (Wheeler, 2015), which is normal.

Pressure on the baby’s head during vaginal delivery can change the shape of the newborn’s head. This process is known as moulding and may result in oedema (some collection of fluid) on the scalp (Kain & Mannix, 2018). Caput succedaneum is the medical term for this swelling. It normally resolves within a few days after birth (Kain & Mannix, 2018).

If you note a collection of blood on the baby’s scalp, this is known as cephalhaematoma and if the scalp has a ‘boggy’ consistency with mobile fluid moving across the suture lines of the skull, this may indicate a more serious problem, known as subgaleal haemorrhage (Kain & Mannix, 2018). This requires urgent medical intervention.

The initial measurement of the head circumference after birth provides a baseline to work from, as comparison measurements will continue throughout infancy and toddlerhood up until around 3 years of age. Head circumference is one of the indicators of brain growth and is plotted on standard growth charts.

If the head circumference is too small or too large this may indicate a congenital or developmental disorder (Harris, 2015). To measure the newborn’s head circumference, it’s best to use a paper tape measure. Place it in a line above the eyebrows, and the pinna of the ears and around to the occipital prominence of the skull, which is the widest part of the back of the baby’s skull (Forster & Marron, 2018).

Inspecting the baby’s hair

Note the amount of hair and coverage. Some newborns will have very little head hair whereas others will have abundant, thick locks. Again, genetics and ethnic origin will play a hand in this.

Ensure you make a note of the hairline. If the hairline is low and the muscle tone of the baby is also low, it may indicate a condition known as neonatal hypothyroidism. This occurs when the thyroid gland is not producing sufficient hormones (Kain & Mannix, 2018).

Your task

Watch the video and post your comments and questions about assessment of the newborn’s head, using the link below. We look forward to hearing from you.

References

Forster, E. & Marron, C. (2018). Paediatric Assessment Skills. In E.Forster & J.Fraser. Paediatric Nursing Skills for Australian Nurses. Port Melbourne, Victoria: Cambridge.

Harris, S.R. (2015). Measuring head circumference: Update on Infant Microcephaly. Canadian Family Physician, 61 (8) 680-684.

Kain, V. & Mannix, T. (2018). Neonatal Nursing in Australia and New Zealand, 1st Edition. Australia: Elsevier

The moment your baby is born can be very special, but there’s usually a lot going on too. What happens straight after birth will depend on your labour, how your baby is born, and how quickly your baby adapts to life outside the womb.

Uncomplicated vaginal birth
Most babies breathe and cry within a few seconds of being born.

If your baby is breathing well, baby can be placed naked, skin to skin, on your chest or belly straight after birth. Skin-to-skin contact keeps your baby warm, helps to steady your baby’s breathing and heart rate, and lets you and baby bond physically straight away. It’s also a trigger for breastfeeding.

The midwife will dry your baby while your baby is on you, and cover you both with a warm blanket or towels.

If you prefer, your baby can be dried, wrapped in warm towels or blankets for you to hold.

Forceps or vacuum birth
Most babies born with the help of forceps or a vacuum will breathe and cry at birth. But some babies might be a little stunned or slow to breathe, especially if they’re distressed during labour. If this happens, the midwife, obstetrician or paediatrician will take your baby to a special warming station. They’ll dry your baby and check baby’s breathing.

You can hold your baby once baby is breathing properly. You can ask for skin-to-skin contact. Or your baby can be dried, wrapped in warm towels or blankets for you to hold.

Elective caesarean section
Most babies born via elective caesarean section breathe and cry vigorously at birth.

If baby is breathing well, you might be able to have skin-to-skin contact before baby goes to a special warming station to be dried and checked. Sometimes baby’s breathing will be checked before baby is handed back for you to hold. You can ask to hold your baby skin to skin, or baby can be wrapped in warm blankets or towels for you to hold while on the operating table.

Sometimes you might need further medical attention, so that first cuddle might have to wait. Your birth partner can stay with your baby and give baby lots of cuddles and skin-to-skin contact until you get back to recovery or the maternity ward.

Unplanned (emergency) caesarean section
Babies born via unplanned caesarean section are more likely to need help to breathe at birth. The midwife or paediatrician will take your baby to a special warming station for drying. They’ll also check what type of help your baby needs.

When your baby is breathing well and your health is stable, you can hold your baby. Even if you’re still on the operating table, it’s OK to ask for skin-to-skin contact or cuddles.

If you’ve had a general anaesthetic, you’ll be able to hold your baby after you’ve recovered.

If your baby needs a lot of help to breathe at birth, your baby might need to go straight to the neonatal intensive care unit (NICU). Your first cuddle might have to wait until your baby is well.

Cutting the cord

After the birth of your baby, the umbilical cord needs to be clamped and cut. This can happen straight after birth, or you might be able to cuddle your baby for a minute or two before the cord is cut.

Your birth partner can usually cut the umbilical cord if that’s what you and your partner want. They won’t be able to cut the umbilical cord if your baby is born by caesarean section or needs to be taken quickly to the warming station after birth, or if you have complications like heavy bleeding. In this situation, the midwife or obstetrician will clamp and cut the cord.

The cord is quite tough to cut, but cutting it isn’t painful for you or your baby.

You can bond with your newborn baby as soon as your baby arrives. Early skin-to-skin contact is a great way to do this, whether it’s cuddling your baby on your chest or encouraging baby to breastfeed.

How your baby will look and behave after birth

It’s normal for your baby to look blue or purple in the initial few minutes after birth. If your baby is breathing well, your baby’s skin colour will gradually become pink within 7-10 minutes after birth. Your baby’s hands and feet might stay blue for up to 24 hours. This is because the blood vessels in your baby’s hands and feet are very small, and it takes time for blood to circulate properly there and turn them pink.

If all is well, most babies cry immediately after birth. Most then quietly gaze with large open eyes at their surroundings before falling asleep. But some might stay awake and want to feed.

If your baby seems ready, you can try breastfeeding within a few minutes of birth. The midwife will help you attach baby to your breast.

One of the keys to making breastfeeding work for you and baby is getting a good attachment at your breast. You can see how in our baby-led attachment video and our illustrated guide to breastfeeding. You can also read more about breastfeeding attachment techniques.

The Apgar score

The Apgar score is a rating of your baby’s heart rate, breathing, muscle tone, response to stimuli and skin colour. A score of 0, 1 or 2 is given for each of these five criteria, and the total is the Apgar score.

Your baby’s Apgar score measures how well your baby has made the transition from life inside the womb to life outside. Apgar scores are recorded in your baby’s child health and development book.

When your baby needs medical help after birth

If your baby isn’t breathing properly after birth and needs help to breathe, has a low heart rate (below 100 beats per minute) or is floppy, baby will be moved to the warming station. Staff will decide what sort of extra medical help your baby needs.

The doctor or midwife might clear your baby’s airways and help your baby to breathe by giving normal air through a special baby mask and breathing device. The breathing device and face mask might stay on until your baby can breathe independently.

If your baby’s breathing, heart rate and floppiness don’t improve, your baby might need oxygen through a mask or breathing tube.

If your baby needed help to breathe at birth, your baby will be taken to the special care nursery (SCN) or NICU for further assessment and close monitoring.

Most babies start breathing quickly in response to simple actions like drying and stimulation. Very few babies need help to start breathing. And fewer than 3 in 1000 babies need more active resuscitation like chest compressions (CPR) and drugs.

Checks and medications in the first 24 hours

Within the first hour of birth, the midwife will put two name tags on your baby.

Your baby will also be weighed at some time in the first few hours. When weighing your baby, the midwife will do a quick physical check.

The midwife will record when your baby first poos and wees. This is usually within the first 24 hours.

You’ll be asked to give your permission for your baby to have one or two injections. These injections are given into the thigh muscles after birth, either immediately or within a few hours. The injections are:

• vitamin K – this can help prevent a bleeding disorder caused by a vitamin K deficiency (haemorrhagic disease of the newborn)
• hepatitis B immunisation – this is the only immunisation required at birth, and is given as part of Australia’s universal immunisation program.

You can discuss these procedures with your midwife, GP or obstetrician at one of your appointments towards the end of your pregnancy.

Within the first 48-72 hours of your baby’s life, you’ll be asked to give your consent for newborn screening, which tests your baby for signs of rare conditions. In the early days, your baby will also be checked for developmental dysplasia of the hip (DDH) and screened for deafness and hearing impairment.