Lesson (6): Assessment of

Gestational Age

DR. ATYAT
 Outlines of Gestational Age Assessment

Definition
Estimation of gestational age
Definition of the New Ballard Score
Ballard Exam
Procedure of gestational age assessment

DR. ATYAT
 Definition of gestational age
• Number of weeks that have elapsed since the
first day of the last menstrual period to the
time of birth

DR. ATYAT
 Estimation of gestational age
– Physical and neuromuscular examination
– L.M.P.
– Lab test
– Obstetric history
– Fetal ultrasonic

DR. ATYAT
 Definition of the New Ballard Score
• The New Ballard Score is a set of procedures developed
by Dr. Jeanne L Ballard, MD to determine Gestational
Age through neuromuscular and physical assessment of
a newborn fetus.
• Ballard Exam

• Focuses on physical and neuromuscular characteristics

• Best done between 12 and 20 hours of life

• Accurate within 2 weeks

DR. ATYAT
Procedure: Gestational age assessment

Getting Ready
1. Perform hand hygiene before patient contact.
2. Verify the correct newborn using two
identifiers.
3. If moving the newborn to a radiant warmer for
examination, preheat it and apply clean linen.
DR. ATYAT
4.Place the newborn on the radiant warmer or in an

incubator/Isolette. Undress the newborn and apply

temperature probe with reflective disk to the proper

location.

5.Provide comfort measures as needed.

6.Collect supplies and place a copy of the New Ballard Score

(NBS) tool at the bedside.

7.Obtain an NBS documentation sheet and follow the order

of assessment detailed there.

DR. ATYAT
 1. Posture
NEURO-MUSCULAR MATURITY SCORE
SIGN SIGN
SCORE
-1 0 1 2 3 4 5

Posture

 Observe posture while the newborn is supine and quiet. Remove positioning aids if
necessary. Newborns delivered in the breech position typically have extended legs.
Resting posture is hypotonic in newborns
DR. of very early gestation.
ATYAT
 2. Square Window
NEURO-MUSCULAR MATURITY SCORE
SIGN SIGN
SCORE
-1 0 1 2 3 4 5

Square
Window

 Perform square window examination:

a. Press gently on the knuckles to
straighten the fingers.
b. Using gentle pressure, flex the
newborn's hand at the wrist of
the arm without the ID band,
attempting to place the palm of
the hand flat on the forearm.
c. Bend the hand as far down as
possible and measure the angle
between palm and forearm.
DR. ATYAT
 3. Arm Recoil
NEURO-MUSCULAR MATURITY SCORE
SIGN SIGN
-1 0 1 2 3 4 5 SCORE

Arm
Recoil

 Test arm recoil. Hold the newborn's arms fully flexed for 5 seconds, then fully
extend them by pulling the hands down to the sides, and release quickly.
DR. ATYAT
 4. Popliteal Angle
NEURO-MUSCULAR MATURITY SCORE
SIGN
SIGN
-1 0 1 2 3 4 5 score

Popliteal
Angle

 Measure popliteal angle:

a. Place the newborn supine with pelvis
flat.
b. With the index finger of one hand, hold
the newborn's thigh in a knee-chest
position without pulling the hip off the
bed.
c. Using the other hand, place the index
finger behind the ankle and gently
extend the leg just until resistance is
felt.
d. Measure the angle between thigh and
underside of the calf. Newborns
delivered in the breech position
exhibit a greater angle even if they DR. ATYAT
are full term.
 5. Scarf Sign
NEURO-MUSCULAR MATURITY SCORE
SIGN
SIGN
-1 0 1 2 3 4 5 SCORE

Scarf
Sign

 Perform scarf sign. With the

newborn supine, gently take his or
her hand and pull the arm across the
neck as far as possible toward the
opposite shoulder. Note the position
of elbow to midline as diagrammed
on the scoring sheet.
DR. ATYAT
 6. Heel to Ear
NEURO-MUSCULAR MATURITY SCORE SIGN
SIGN SCOR
-1 0 1 2 3 4 5 E

Heel
To Ear

 Assess heel to ear. With the newborn

supine, grasp the foot and gently pull
leg up toward ear on same side as
close as possible without forcing it.
Assess position of leg in relation to
body. Newborns delivered in the
breech position exhibit greater
extension than normal for their
DR. ATYAT
GA.
 1. Skin
PHYSICAL MATURITY SCORE SIGN
SIGN SCOR
E
-1 0 1 2 3 4 5

Sticky, gelatinous, smooth superficial Parchment

cracking, leathery,
friable, red, pink, peeling , deep
Skin pale areas, cracked,
trans- translucen visible &/or rash, cracking,
rare veins wrinkled
parent t veins few veins no vessels

 Assess skin for color, thickness, texture, and visibility of the veins, particularly on the
DR. ATYAT
abdomen.
 2. Lanugo
PHYSICAL MATURITY SCORE
SIGN SIGN
SCORE
-1 0 1 2 3 4 5

Lanugo none sparse abunda

nt
bald
thinning areas mostly
bald

 Assess lanugo (body hair), first on the face and anterior trunk, then on the rest of the body.
DR. ATYAT
 3. Plantar Surface
PHYSICAL MATURITY SCORE SIGN
SIGN
-1 0 1 2 3 4 5 SCORE
anterior
creases
heel-toe faint transvers
Plantar >50 creases over
40-50mm: -1 red e
Surface no crease ant. 2/3 entire
<40mm: -2 marks crease
sole
only

 Assess plantar surfaces.

Evaluate soles of feet for
length, as well as for presence
and location of creases. Plantar
creases are not a valid
indicator of GA after 12 hours
of age.
DR. ATYAT
 4. Breast
PHYSICAL MATURITY SCORE
SIGN SIGN
SCORE
-1 0 1 2 3 4 5

barely stippled Raised full

Imper- flat
per- areola areola areola
Breast ceptabl areola
ceptabl 1-2mm 3-4mm 5-10mm
e no bud
e bud bud bud

 Measure nipple size and amount of

breast tissue. Use two fingers to
gently palpate breast tissue and
measure in millimeters. An
inaccurate measurement may
result from too much tissue being
drawn together. DR. ATYAT
 5. Eye / Ear
PHYSICAL MATURITY SCORE
SIGN
SIGN
SCO
-1 0 1 2 3 4 5 RE

sl. curved well-curved Formed

lids fused lids open thick
Eye / pinna; pinna; & firm
loosely: -1 pinna flat cartilage
Ear soft; soft but instant
tightly: -2 stays folded ear stiff
 Evaluate the eyes and ears: slow recoil ready recoil recoil

1. For very premature newborns, assess degree of

eyelid fusion. Fused eyelids open at 26 to 28
weeks' gestation.
2. For all but very premature newborns, assess
shape, recoil, and cartilage content of ear:
a. Shape: Pinna (outer edge of ear)
should be well curved in the term
newborn.
b. Recoil: Ear should spring back readily
when folded down and released.
c. Cartilage: Entire ear should be stiff
and firm in the term newborn.DR. ATYAT
 6. Genitals-Male
PHYSICAL MATURITY SCORE SIGN
SIGN SCOR
-1 0 1 2 3 4 5 E

Genital scrotu
m
scrotum testes in
empty, upper
testes
descendin
testes
down,
testes
pendulous,
s
(Male) smooth rugae rare rugae few g,
flat, faint canal,
rugae
good
rugae
deep
rugae

 Assess the genitalia:

a. Male. Examine scrotum,
placing fingers of one hand
over the inguinal canal and
palpating the scrotal sac with
the other hand. Note the
presence of rugae (wrinkles)
and location of testes.
DR. ATYAT
 7. Genitals-Female
S
IG
SIGN PHYSICAL MATURITY SCORE N
SC
OR
E

-1 0 1 2 3 4 5

promin promi majora

clitoris ent nent & majora majora
Genitals promine clitoris clitoris minora large, cover
(Female) nt & small & equall minora clitoris &
& labia labia enlargi y small minora
flat minora ng promi
minora nent

a. Female. Examine labia majora

(outer), labia minora (inner),
and clitoris.

DR. ATYAT
DR. ATYAT
DR. ATYAT
 Maturity Rating
TOTAL SCORE
WEEKS
(NEUROMUSCULAR + PHYSICAL)
-10 20
-5 22
0 24
5 26
10 28
15 30
20 32
25 34
30 36
35 38
40 40
45 42
50 DR. ATYAT
44
 After the Procedure
1. Return the newborn to the mother or original bed if
moved for the assessment.
2. Add the scores and obtain the estimated GA from the
chart on the NBS sheet.
3. Monitor a preterm newborn closely for signs of
temperature instability and overstimulation.
4. Assess, treat, and reassess pain.
5. Perform hand hygiene.
6. Document the procedureDR. in
ATYAT
the newborn's record.
ALERT
All newborns should have a gestational age (GA)
assessment, although it should be considered only an
estimate. Several factors, including maternal medical
issues, maternal medication and drug use, newborn
neurologic disorders, and newborn positional
deformities can influence the examination results.

DR. ATYAT
DR. ATYAT