General examination initial and subsequent assessments

FIGURE 44-2. Intrauterine growth charts showing the normal values of body weight, length, and head circumference for infants born at different gestational ages at sea level (Montreal). (Source: From the data of Usher R, McLean F. Intrauterine growth of live-born Caucasian infants at sea level: standards obtained from measurements in 7 dimensions of infants born between 25 and 44 weeks of gestation. J Pediatr. 1969;74:901-910.)
Ecchymoses generally result from birth trauma and are often present over the head after vertex delivery or on the feet, lower limbs, and buttocks following breech delivery. With severe birth trauma, there can be extensive hemorrhage into the muscles underlying areas of bruised skin. Localized petechiae are usually found in areas of vascular stasis or compression that occurred during delivery, on the face after a vertex delivery, or on the lower limbs after a breech delivery. More generalized petechiae suggest thrombocytopenia.
The skin overlying an area of subcutaneous fat necrosis often appears red. The subcutaneous tissue is hard and sharply demarcated, with lesions most common on the cheeks, buttocks, limbs, or back.
Neonatal jaundice, with a yellow skin color, is caused by an elevation in indirect-reacting bilirubin. Elevation of direct-reacting bilirubin gives a yellow-to-green discoloration. It is easier to assess jaundice in a newborn by briefly pressing on the infant’s skin with a finger and observing the color in the blanched area. This is of particular value in pigmented infants. The normal newborn commonly develops mild physiologic jaundice between days 2 and 4 after birth. Jaundice in the first day warrants prompt investigation; it is usually from sepsis or hemolytic anemia. The differential diagnosis of neonatal jaundice is discussed in Chapter 53.
HEAD
Scalp hair of the infant is fine and silky. The head shape differs in infants who were in vertex or breech positions. After vertex presentation and vaginal delivery, there can be pronounced vertical elongation of the head. Breech infants often have occipital-frontal head elongation, with a prominent occipital shelf.
The cranial sutures should be palpably open and may be separated by up to several millimeters. Temporary overlap of bones, due to molding, should be distinguished from craniosynostosis (premature closure of a suture). If a suture closes in utero, it prevents growth of the skull perpendicular to the fused suture line, resulting in a sustained, abnormal skull configuration. In contrast, after molding occurs, the bones return to their normal positions in a few days, sometimes with a small concomitant decrease in head circumference.
Normally, the anterior fontanelle is open, soft, and flat; mean diameter is less than 3.5 cm. The posterior fontanelle is often fingertip size or just palpably open. A bulging or tense fontanelle, with separation of the bony sutures, indicates increased intracranial pressure.¹¹