Gestational Age

Assessment of the Newborn

Kristine AA.. Karlsen MSN
MSN,, RNC
RNC,, NNP
Author
National Program Director
Director,, Founder
Founder
The SS.T.A.B.L.E.
.T.A.B.L.E. Program
Program PowerPoint
PowerPoint®® Design
Design
Park City
City,, Utah
Utah Mary Puchalski MS
MS,, RNC
RNC,, APN/CNS
APN/CNS
stable@stableprogram.org
stable@stableprogram.org Lombard
Lombard,, Illinois
Illinois
mary@stableprogram.org
mary@stableprogram.org

Medical
Medical Illustrations
Illustrations
John Gibb MA
© K. Karlsen 2006
 Physical Maturity

Ballard
-1 0 1 2 3 4 5

Sticky Gelatinous Superficial Cracking Parchment Leathery

Smooth pink peeling and/or
Skin Friable Red rash Pale areas Deep cracking Cracked
Visible veins
Transparent Translucent Rare veins No vessels Wrinkled

Gestational
Few veins

Abundant Thinning
Lanugo No lanugo Sparse lanugo lanugo Lanugo Bald Areas Mostly bald

Age
Heel- toe Heel- toe Anterior
Plantar 40-50 mm > 50 mm Faint red marks transverse Creases Creases over
surface < 40 = -2 No crease crease only anterior 2/3 entire sole

Barely Flat areola no Stippled areola Raised areola Full areola

Breast Imperceptible perceptible bud 1-2 mm bud 3-4 mm bud 5-10 mm bud

Assessment
Lids fused: Lids open Slightly Well-curved Formed and
pinna firm Thick cartilage
Eyes / ears Loosely: -1 Pinna flat curved pinna
Soft but ready Instant recoil Ear stiff
Tightly: -2 Stays folded Soft slow recoil recoil
Testes in upper Testes Testes
Male Scrotum flat, Scrotum empty canal descending Testes down pendulous
Genitals smooth Faint rugae Rare rugae Few rugae Good rugae Deep rugae

Clitoris Prominent Prominent

Female clitoris clitoris Majora and Majora large Majora cover
prominent minora equally clitoris and
Genitals Labia flat Small labia Enlarging prominent Minora small minora
minora minora

Neuromuscular Maturity

Posture

Square
window
(wrist)
wrist)

Arm recoil

Adapted from:
Ballard et al. (1991)
Popliteal
angle

J Pediatr., 119(3): 417-423.

Scarf sign

Heel to ear
© K. Karlsen 2006
 Ballard
Gestational
A
A detailed
detailed monograph
monograph and and
explanation
explanation about
about how
how to
to
Age
perform
perform the
the Ballard
Ballard exam
exam

Assessment
((written
written by
by Dr
Dr.. Ballard),
Ballard),
may
may be
be found
found at
at
www .BallardScore.com
www.BallardScore.com

Adapted from: Neuromuscular illustrations were adapted

Ballard et al. (1991) with permission of Dr. Ballard
J Pediatr., 119(3): 417-423.

© K. Karlsen 2006
 Principles of Exam
Timing
Most reliable if performed by 12 hours of life
Keep infant warm

© K. Karlsen 2006
 Ballard Exam  Physical Maturity
-1 0 1 2 3 4 5
Sticky Gelatinous Superficial Cracking Parchment Leathery
Smooth pink peeling Deep
Skin Friable Red and/or rash Pale areas cracking Cracked
Visible veins
Transparent Translucent Few veins Rare veins No vessels Wrinkled
Sparse Abundant Thinning
Lanugo No lanugo lanugo lanugo Lanugo Bald areas Mostly bald

Heel- toe Heel- toe Anterior

Plantar 40-50 mm > 50 mm Faint red transverse Creases Creases over
surface <40 = 2 No crease
marks crease only anterior 2/3 entire sole

Stippled Raised Full areola

Im- Barely Flat areola areola areola
Breast perceptible perceptible no bud
1-2 mm bud 3-4 mm bud 5-10 mm bud

Lids fused: Lids open Slightly Well-curved Formed Thick

Eyes / Loosely: -1 Pinna flat curved pinna pinna and firm cartilage
ears Soft slow Soft but Instant recoil Ear stiff
Tightly: -2 Stays folded recoil ready recoil
Scrotum Testes in Testes Testes
Male Scrotum empty upper canal descending Testes down pendulous
Genitals flat, smooth Faint rugae Rare rugae Few rugae Good rugae Deep rugae
Clitoris Prominent Prominent Majora and
Female prominent clitoris clitoris minora Majora large Majora cover
clitoris and
Genitals Labia flat Small labia Enlarging equally Minora small minora
minora minora prominent
© K. Karlsen 2006
 Skin
-1 0 1 2 3 4 5
Smooth Superficial Parchment
Sticky Gelatinous Cracking Leathery
pink peeling Deep
Friable Red and/or rash Pale areas Cracked
Visible cracking
Transparent Translucent veins Few veins Rare veins Wrinkled
No vessels

-1 0 1

© K. Karlsen 2006
 Skin
-1 0 1 2 3 4 5
Smooth Superficial Parchment
Sticky Gelatinous Cracking Leathery
pink peeling Deep
Friable Red and/or rash Pale areas Cracked
Visible cracking
Transparent Translucent veins Few veins Rare veins Wrinkled
No vessels

© K. Karlsen 2006
 Skin
-1 0 1 2 3 4 5
Smooth Superficial Parchment
Sticky Gelatinous Cracking Leathery
pink peeling Deep
Friable Red and/or rash Pale areas Cracked
Visible cracking
Transparent Translucent veins Few veins Rare veins Wrinkled
No vessels

3 5
4

© K. Karlsen 2006
 Lanugo
-1 0 1 2 3 4

No lanugo Sparse Abundant Thinning Bald areas Mostly bald

Begins to appear 24 – 25 weeks

Abundant across shoulders and upper back by 28 weeks
With increasing gestation
Lower back area thins first
Bald areas appear over lumbo-sacral area
Mostly bald by term
Amount and location may vary with nutritional status,
ethnicity, hormonal and metabolic factors

© K. Karlsen 2006
 Lanugo
-1 0 1 2 3 4

No lanugo Sparse Abundant Thinning Bald areas Mostly bald

-1 0

© K. Karlsen 2006
 Lanugo
-1 0 1 2 3 4

No lanugo Sparse Abundant Thinning Bald areas Mostly bald

© K. Karlsen 2006
 Lanugo
-1 0 1 2 3 4

No lanugo Sparse Abundant Thinning Bald areas Mostly bald

© K. Karlsen 2006
 Lanugo
-1 0 1 2 3 4

No lanugo Sparse Abundant Thinning Bald areas Mostly bald

2 3

© K. Karlsen 2006
 Plantar Surface
-1 0 1 2 3 4
Heel–toe Anterior Creases
> 50 mm Faint red Creases
40 – 50 mm transverse over entire
No crease marks anterior 2/3
< 40 = – 2 crease only sole

-1
0 1

© K. Karlsen 2006
 Plantar Surface
-1 0 1 2 3 4
Heel–toe Anterior Creases
> 50 mm Faint red Creases
40 – 50 mm transverse over entire
No crease marks anterior 2/3
< 40 = – 2 crease only sole

3 4

© K. Karlsen 2006
 Breast
-1 0 1 2 3 4
Stippled Raised Full areola
Im- Barely Flat areola areola areola
perceptible perceptible no bud 5–10 mm
1–2 mm bud 3–4 mm bud bud

-1 0 1

© K. Karlsen 2006
 Breast
-1 0 1 2 3 4
Stippled Raised Full areola
Im- Barely Flat areola areola areola
perceptible perceptible no bud 5–10 mm
1–2 mm bud 3–4 mm bud bud

2 3 4

© K. Karlsen 2006
 Eye and Ear
-1 0 1 2 3 4

Lids fused: Lids open Slightly Well-curved Formed

Thick
curved pinna pinna and firm
Loosely: -1 Pinna flat cartilage
Soft slow Soft but Instant
Tightly: -2 Stays folded Ear stiff
recoil ready recoil recoil

-2 0

© K. Karlsen 2006
 Eye and Ear
-1 0 1 2 3 4

Lids fused: Lids open Slightly Well-curved Formed

Thick
curved pinna pinna and firm
Loosely: -1 Pinna flat cartilage
Soft slow Soft but Instant
Tightly: -2 Stays folded Ear stiff
recoil ready recoil recoil

1 2 3 4

© K. Karlsen 2006
 Genitalia  Male
-1 0 1 2 3 4
Scrotum Testes in Testes Testes Testes
Scrotum empty upper canal descending down pendulous
flat, smooth
Faint rugae Rare rugae Few rugae Good rugae Deep rugae

0 1 2 3 4

© K. Karlsen 2006
 Genitalia  Female
-1 0 1 2 3 4
Prominent Prominent Majora and Majora Majora
Clitoris
clitoris clitoris minora large cover
prominent
Small labia Enlarging equally Minora clitoris and
Labia flat prominent minora
minora minora small

0 3 4

© K. Karlsen 2006
Ballard Exam  Neuromuscular Maturity
-1 0 1 2 3 4 5

Posture

Square
window
(wrist)

Arm
recoil

Popliteal
angle

Scarf
sign

Heel to
ear
© K. Karlsen 2006
 Principles of Neuromuscular Exam
Positioning !! Neuromuscular
Neuromuscularassessment
assessmentmay maybe betoo
too
Head midline stressful
stressfulfor
forpremature
prematureandandsick
sickinfants
infants
sshould
hould bebeperformed
performedby byskilled
skilled
Hips flat neonatal
neonatalICU
ICUpersonnel
personnelonce
onceinfant
infant
stabilized
stabilizedand
andable
ableto
totolerate
toleratethe
theexam
exam

Reliability of
exam altered by:
Sedation
Anesthesia
Paralysis
Critically ill state
Breech position

© K. Karlsen 2006
 Posture
-1 0 1 2 3 4

1 2

© K. Karlsen 2006
 Posture
-1 0 1 2 3 4

3 4

© K. Karlsen 2006
 Square Window
-1 0 1 2 3 4

>90 90 60 45 30 0

Assesses wrist flexibility and/or resistance to extensor

stretching at the wrist
Press gently on knuckles to straighten fingers
Apply gentle pressure on back of hand close to
fingers  avoid wrist rotation
Stop pressing when resistance felt
Angle decreases as gestational age increases

© K. Karlsen 2006
 Square Window
-1 0 1 2 3 4

>90 90 60 45 30 0

0 1

© K. Karlsen 2006
 Square Window
-1 0 1 2 3 4

>90 90 60 45 30 0

2 3 4

© K. Karlsen 2006
 Arm Recoil
-1 0 1 2 3 4

180 140-180 110-140 90-110 <90

Tests for passive flexor tone of biceps muscle

Test one arm at a time in order to avoid the Moro reflex
Supine position
Hold infant’s hand
Briefly flex arm  then momentarily extend arm and
release hand
Scores based on angle of recoil when arms return
to flexion

© K. Karlsen 2006
 Arm Recoil
-1 0 1 2 3 4

180 140-180 110-140 90-110 <90

1 3 4

© K. Karlsen 2006
 Popliteal Angle
-1 0 1 2 3 4 5

180 160 140 120 100 90 <90

Assesses maturation of passive flexor tone about the

knee joint
Refrain from touching hamstrings (muscle group being
tested) during maneuver
Thigh placed in knee-chest position with knee fully flexed
Allow infant to relax, then grasp foot at sides
Extend leg until resistance is felt
Estimate angle behind the knee
Measurement unreliable if frank breech in utero
© K. Karlsen 2006
 Popliteal Angle
-1 0 1 2 3 4 5

180 160 140 120 100 90 <90

0 1

© K. Karlsen 2006
 Popliteal Angle
-1 0 1 2 3 4 5

180 160 140 120 100 90 <90

2 3 4

© K. Karlsen 2006
 Scarf Sign
-1 0 1 2 3 4

neck axillary line nipple line xyphoid process nipple line axillary line

Tests passive tone of the posterior shoulder girdle

flexor muscles
Supine position with head midline
Hold infant’s hand across chest and use thumb of other
hand to gently push elbow across chest
Or, gently pull arm across chest (shown in photos)
Stop when resistance is felt
Scores based on position of elbow at landmarks

© K. Karlsen 2006
 Scarf Sign
-1 0 1 2 3 4

neck axillary line nipple line xyphoid process nipple line axillary line

1 2

© K. Karlsen 2006
 Scarf Sign
-1 0 1 2 3 4

neck axillary line nipple line xyphoid process nipple line axillary line

3 4

© K. Karlsen 2006
 Heel-to-Ear
-1 0 1 2 3 4

ear nose chin nipple line umbilical area femoral crease

Tests for passive flexion or resistance to extension

of posterior hip flexor muscles
Refrain from touching gluteus muscle (muscle group
being tested) during maneuver
Rest leg alongside body
Grasp foot along both sides
Gently pull toward ear until resistance felt
Scores based on location of heel to landmarks
Measurement unreliable if frank breech in utero
© K. Karlsen 2006
 Heel-to-Ear
-1 0 1 2 3 4

ear nose chin nipple line umbilical area femoral crease

© K. Karlsen 2006
 Heel-to-Ear
-1 0 1 2 3 4

ear nose chin nipple line umbilical area femoral crease

3 4

© K. Karlsen 2006
Gestational
Physical Maturity

Age
-1 0 1 2 3 4 5

Sticky Gelatinous Superficial Cracking Parchment Leathery

Smooth pink peeling and/or
Skin Friable Red rash Pale areas Deep cracking Cracked
Visible veins

Evaluation
Transparent Translucent Few veins Rare veins No vessels Wrinkled

Abundant Thinning
Lanugo No lanugo Sparse lanugo lanugo Lanugo Bald Areas Mostly bald

Heel- toe Anterior

Plantar 40-50 mm > 50 mm
Faint red marks transverse Creases Creases over
surface < 40 = -2 No crease crease only anterior 2/3 entire sole

Sum scores
Barely Flat areola no Stippled areola Raised areola Full areola
Breast Im-perceptible perceptible bud 1-2 mm bud 3-4 mm bud 5-10 mm bud

Lids fused: Lids open Slightly Well-curved Formed and

pinna firm Thick cartilage
Eyes / ears Loosely: -1 Pinna flat curved pinna
Soft but ready Instant recoil Ear stiff
Tightly: -2 Stays folded Soft slow recoil recoil

10
Testes in upper Testes Testes
Male Scrotum flat, Scrotum empty canal descending Testes down pendulous
Genitals smooth Faint rugae Rare rugae Few rugae Good rugae Deep rugae

Clitoris Prominent Prominent

Female clitoris clitoris Majora and Majora large Majora cover
prominent minora equally clitoris and
Genitals Labia flat Small labia Enlarging prominent Minora small minora
minora minora

Neuromuscular Maturity

Posture

Square
window
(wrist)
wrist)

Arm recoil

10 + 15 = 25
Popliteal
angle

Scarf sign

Heel to ear 15
© K. Karlsen 2006
Gestational Score Wks

Age -10 20

Evaluation
-5 22
0 24
Sum scores 5 26
Neuromuscular 10 28
Physical maturity 15 30
Total score correlates to 20 32
weeks gestation
25 34
30 36
35 38
40 40
10 + 15 = 25 45 42
50 44
© K. Karlsen 2006
A detailed monograph and explanation about
how to perform the Ballard exam
(written by Dr. Ballard), may be found at
www.BallardScore.com