INFANT NAME: DATE MIDWIFE:

TIME STAMP 2 1 0 1 MIN 5 MIN

BIRTH MILESTONES

Normal color all over (hands Normal color (but hands and
HEAD OUT Appearance and feet are pink) feet are bluish)
Bluish-gray or pale all over

Normal (above 100 beats per

BIRTH Pulse minute) Below 100 beats/min
Absent (No pulse)

APGAR
Pulls away, sneezes, coughs, or Facial movement only (grimace) Absent (no response to
FIRST BREATH Grimace cries with stimulation with stimulation stimulation)
Arms and legs flexed with little
PLACENTA Activity Active, spontaneous movement
movement
No movement, "floppy" tone

Normal rate and effort, good Slow or irregular breathing,

CORD CUT Respiration cry weak cry
Absent (no breathing)

FIRST LATCH TOTAL

MEASUREMENT Normal/Abnormal

HEART RATE General Skin colour, integrity, perfusion; State of alertness; Activity, range of spontaneous movement ;
appearance Posture, muscle tone

Head shape, size; Scalp, fontanelles, sutures; Eye size, position structure; Nose, position, structure;
NEWBORN MEASUREMENTS

RESPIRATIONS Head, face, neck

NEWBORN EXAMINATION
Ear position, structure; Mouth, palate, teeth, gums tongue, frenulum
TEMPERATURE Shoulders, arms, Length, proportions, symmetry; Structure, number of digits
hands
HEAD Size, shape, symmetry, movement; Breast tissue, nipples; Heart sounds, rate, pulses; Breath
Chest sounds; Pulse oximetry (optional)
CHEST Abdomen Size, shape, symmetry; Palpate liver, spleen, kidneys; Umbilicus; Listen for bowel sounds

ABDOMEN Male - penis, foreskin, testes; Female - clitoris, labia, hymen; Anal position, patency; Passage of
Genitourinary urine, stool
LENGTH Hips, legs, feet Ortolani and Barlow’s manoeuvres; Leg length, proportions, symmetry and digits

WEIGHT Back Spinal column, skin; Symmetry of scapulae, buttocks

GESTATIONAL AGE Behaviour, posture; Muscle tone, spontaneous movements; Cry; Reflexes - Moro, Suck, Grasp,
Neurological Babinski
GIVEN? METHOD LOT # EXP DATE TIME INITIALS
MEDS

VITAMIN K
EYE PROPHYLAXIS
NOTES

ASSESSMENT
 BALLARD SCORE GESTATIONAL AGE ASSESSMENT
-1 0 1 2 3 4 5 SCORE
NEUROMUSCULAR MATURITY

Slight tone in Some flexion in all Frog leg

Posture No visible tone Hips start to flex
elbows and knees joints tone/flexed arm
Square Window > 90° 90° q 45° 30° 0°
Arm Recoil 180° 140 - 180° 110 - 140° 90 - 110° < 90°
Foot to face Foot not quite Some resistance Adequate Adequate Considerable
Popliteal Angle < 90°
(180°) to face (160°) (140°) resistance (120°) resistance (100°) resistance (90°)
Arm
Arm mostly Arm mostly across Arm partially Elbow does not Elbow extends
Scarf Sign completely
across chest chest across chest cross chest from chest
around neck
Heel extends Adequate
Heel to Ear No bend in knee Slight knee bend Knee at 90° angle Knee fully flexed
to ear resistance

Sticky, friable, Red, gelatinous, Smooth, pink, Peeling and/or Cracking; pale Deep cracking; no Leathery; cracked;
Skin
transparent transparent visible veins rash; few veins areas vessels wrinkled
Lanugo None Sparse Abundant Thinning Bald area Mostly bald
> 50mm; no
Plantar Surface 40-50mm Faint red marks Single crease 2/3 crease Creases cover sole
crease
PHYSICAL MATURITY

Barely Slight stippling; Full areola; bud 5-

Breast Imperceptible Flat areola; no bud Raised areola
perceptible small bud 10 mm
Eyes open;
Slow recoil on Soft but ready
Eye/Ear Lids fused pinna stays Firm; instant recoil Stiff cartilage
pinna recoil
folded
Testes
Scrotum flat, Scrotum empty; Testes descending; Testes pendulous;
Male Genitalia undescended; rare
smooth flat rugae sparse rugae deep rugae
rugae
Flat labia;
Small labia Enlarging labia Majora and minora Majora large, Majora cover
Female Genitalia prominent
majora minora match minora small clitoris and minora
clitoris
TOTAL

NOTES:

SCORE CIRCLE ONE -10 -5 0 5 10 15 20 25 30 35 40 45 50

GESTATIONAL AGE CIRCLE ONE 20 22 24 26 28 30 32 34 36 38 40 42 44