This document provides definitions and classifications related to newborn assessment. It defines terms like neonate, gestational age, preterm, term, etc. It describes how newborns can be classified based on gestational age, birth weight, and weight for gestational age. The document also discusses methods for assessing gestational age both antenatally using clinical, biochemical and radiological methods, and after birth using physical and neurological examination criteria like the Ballard Score. The Ballard Score involves assessing 12 physical and neurological criteria to determine gestational age.

2. DEFINITIONS
• NEONATE/NEWBORN: birth to 4 weeks
• EARLY NEONATAL PERIOD: first 7 days
• LATE NEONATAL PERIOD: 7th to <28th day
• NEWLY BORN: first minutes to few hours
• STILLBIRTH: fetal death at a GA of 22 weeks or
more or weighing more than 500 grams
• PERINATAL PERIOD: 22 weeks of gestation to
7 completed days after birth

3. DEFINITIONS
• Gestational age (completed weeks): time
elapsed between the first day of the last
menstrual period and the day of delivery.
• Postnatal (chronological) age (days, weeks,
months or years): age since birth
• Postmenstrual age (weeks): Gestational age plus
chronological age
• Corrected age (weeks or months): chronological
age reduced by the number of weeks born before
40 weeks of gestation. This term should be used
only for children upto 3 years of age who were
born preterm

4. Newborn Classification
• Classification by Gestational Age
• Classification by Birth Weight
• Classification by Weight for Gestational
Age

5. Classification by Gestational Age
• PRETERM: less than 37 weeks of gestation (259 days)
< 32 weeks : VERY PRETERM births
320/7 and 336/7 weeks: MODERATE PRETERM
340/7 and 366/7 weeks: LATE PRETERM births
‘NEAR TERM’ is no longer used to refer to the third group
(Late preterm), because the phrase falsely conveys a
message that such “borderline” preterm infants are almost
as mature as term infants
• TERM: completed 37-416/7 weeks of gestation (260-294
days)
• POST-TERM: 42 weeks of gestation or more (295 days)

6. • WHO defines PRETERM BIRTH as a birth
occurying either before 37 COMPLETED weeks of
gestation OR on or before the 259th day, counting
from the first day of LMP.
• ONLY completed weeks of gestation are reported.
Therefore an infant born 6 days after completing
35 weeks of gestation is noted as 35 weeks, not
rounded upto 36 weeks (356/7weeks)

7. Classification by Birth Weight
• MACROSOMIA: more than 4000 grams
• NORMAL: between 2500 - 4000 grams
• LBW: birth weight less than 2500 grams,
more than 1500 grams
• VLBW: birth weight less than 1500 grams,
more than 1000 grams
• ELBW: birth weight less than 1000 grams

9. Classification by Weight for
Gestational Age
• AGA: birth weight between 10th and 90th
centile for gestational age
• SGA: birth weight below 10th centile for
gestational age
• LGA: birth weight greater than 90th centile for
gestational age

11. SGA vs IUGR
• SGA and IUGR are not synonymous
• SGA describes a neonate whose birth weight or
birth crown-heel length is <10th percentile for GA
or <2 SD below the mean for the infants GA
• IUGR describes diminished growth velocity in the
fetus as documented by atleast 2 intrauterine
growth assessments
• All IUGR babies can be SGA but,
not all SGA babies are IUGR

12. ASSESSMENT OF GESTATIONAL AGE
• The first aim is to establish if the baby is term
or preterm
• The next aim should be to assess the exact
gestational age in weeks of completed
gestation
• For classification of babies on the basis of
birth weight and gestational age, it is
mandatory that accurate gestational age of
the baby should be known.

13. GESTATIONAL AGE ASSESSMENT
Antenatal assessment of gestational age
• Clinical
• Biochemical
• Cytological
• Radiological
Assessment of gestation after birth
• Physical and Neurological characteristics/criteria

14. Antenatal assessment of
gestational age - CLINICAL
• EDD is calculated by adding 9 months and 7 days to the
1st day of mother’s LMP (NAEGELE’S RULE) – reliable
only if the menstrual cycles are regular and unmodified
by oral contraceptives or maternal diseases, and the
last menstrual period has been normal for flow and
duration
• Height of the uterine fundus during early pregnancy –
16weeks: just above pubic symphysis
• Date of quickening: 18th week
• Appearance of fetal heart sounds: 16-18 weeks
• Fetal form and femur length by ultrasonic techniques
• Maternal weight gain

15. Antenatal assessment of
gestational age - BIOCHEMICAL
• Organic constituents in the liquor amnii, creatinine and
urea progressively rise with advancing maturity while
protein, glucose, lactic and pyruvic acids progressively
decline
• Rise in creatinine is due to increasing muscle mass as
the baby grows and would under-estimate the maturity
of small for dates babies.
• Amniotic fluid creatinine level of >2mg/dl is associated
with gestational maturity of atleast 36 weeks
• Lecithin/Spingomyelin ratio of >2 is indicative of
satisfactory lung maturity, except in mothers with
diabetes mellitus

16. Antenatal assessment of
gestational age - CYTOLOGICAL
• Vaginal wall cytology shows the presence of more
superficial cells as term approaches
• Amniotic fluid cytology for organophilic squame cells,
which are stained orange with Nile blue sulfate, is a
reliable method for prenatal assessment of gestation.
These anucleated orange staining cells derived from
sebaceous glands of the fetus,
a) Increase after 38 weeks of gestation
b) 32-37 weeks: about 10% of amniotic cells show these
characteristics
c) Before 30 weeks: practically no such cells are seen

17. Antenatal assessment of
gestational age - RADIOLOGICAL
• The ossification centers at the lower femoral
and upper tibial epiphyses appear at 36 weeks
and 38 weeks respectively
• Intrauterine growth retardation and cretinism
delay the ossification
• The absence of an ossification center,
therefore, does not indicate immaturity, but
its presence and size are indicative of maturity

18. Assessment of gestation after birth
• The clinical assessment of gestation at birth by Physical
and Neurological Examination of the baby is MORE
RELIABLE as compared to methods recommended for
assessment of baby in utero
• As gestation proceeds, the baby grows and matures
physically and neurologically.
• Anthropometric measurements- weight, length, HC
and CC are unreliable parameters of maturity because
they may be adversely affected by IUGR
• HC and length are relatively spared in a baby with
intrauterine malnutrition as compared to weight and
CC

19. Physical and Neurological
Characteristics
• These characters together can reliably provide
an estimate of GA after the child is born.
• SCORING SYSTEMS: Dubowitz score and
Ballard score are the 2 most extensively
studied and reported scoring systems for
assessing the GA of a neonate

20. DUBOWITZ SCORE
• Was based on assessment of 22 items (10
neurological signs and 12 external signs)
• It was cumbersome and time consuming
• It was gradually replaced by the Ballard score,
which is easier to perform

21. BALLARD SCORE
• Is based on 6 neurological criteria and 6 physical criteria
• Compared to reliable ultrasound dates, Ballard score tended
to overestimate the GA of preterm infants and underestimate
that of post term infants. It was particularly inaccurate in
ELBW infants, with deviations of over 2 weeks
• Inspite of inaccuracies, most studies were based on Dubowitz
or original Ballard maturation assessments
• To be done within 24 hours of life
• Less reliable after 7 days of age
• In babies with neurological compromise (birth asphyxia), the
composite score cannot be used to determine gestation as it
underestimates the gestation (if hypotonic) and
overestimates, if hypertonic

22. • Further modification of the original Ballard scores
and comparison with dates by ultrasound
produced the NEW BALLARD SCORE (NBS), which
includes ELBW babies.
• This method expands the description of physical
and neurologic features and can be used in
infants from 20 to 44 weeks gestation.
• Correlation is similar when the examination is
performed upto 96 hours of age in infants of
atleast 26 weeks gestation but best if done prior
to 12 hours in infants less than 26 weeks
• NBS has an accuracy of ± 2 weeks

24. NeuromuscularCriteria
– Posture(0to4)
• Observe the infant in an
unrestrained position on
back and estimate the
degree of flexion or
extension of extremities.
• As maturation
progresses, there is
increase in flexion of
extremities

25. NeuromuscularCriteria
– SquareWindow(-1to4)
• Flex the wrist and measure the minimum
angle between the hypothenar eminence and
the ventral surface of forearm
• There is a decrease in angle as maturation
progresses

26. NeuromuscularCriteria
– ArmRecoil(0to4)
• The examiner places one hand
beneath the neonate’s elbow for
support.
• With infant supine and head in
midline, first flex the elbow and
hold the arm against forearm for 5
seconds.
• Then, fully extend the elbow and
release
• Note the time taken to resume
flexed posture
• As gestational age increases, there
is an decrease in angle and rapidity
of recoil increases

27. NeuromuscularCriteria
– PoplitealAngle(-1to5)
• Flex the hips and thighs held
in knee-chest position over
the abdomen
• Without lifting the hips from
the bed surface, support the
side of the thigh with 1 hand
and extend the knee as far as
possible with another hand
• Estimate the popliteal angle
• There is a decrease in angle
as maturation increases

28. NeuromuscularCriteria
– ScarfSign(-1to4)
• The tone of the shoulder
girdle is assessed by taking the
baby’s hand and pulling the
hand to the opposite shoulder
like a scarf
• The thumb of the examiner’s
other hand is placed on the
infant’s elbow
• In a term baby, the hand
should not go past the
shoulder and the elbow
should not cross the midline
of the chest

29. NeuromuscularCriteria
– HeeltoEarManeuver(-1to4)
• Place the infant supine with
pelvis flat on table.
• Grasp one foot with thumb
and index finger and draw foot
as near to ipsilateral ear as
possible.
• The examiner feels for
resistance to extension of the
posterior pelvic girdle flexors
and notes the location of the
heel where significant
resistance is appreciated

31. Physical Criteria
– Skin Texture (-1 to 5)
• Before the development of epidermis with
its stratum corneum, the skin is
transparent and adheres somewhat to the
examiner’s finger.
• Later it smoothens, thickens and produces
a lubricant, the vernix, that dissipates
toward the end of gestation
• At term and post-term, the fetus expel
meconium into the amniotic fluid. This
may add an accelerating effect to the
drying process, causing peeling, cracking,
dehydration and imparting a parchment,
then leathery, apperance to the skin

32. Physical Criteria
– Lanugo Hair (-1 to 4)
• Fine downy hair covering fetus
from 20-28 weeks
• Disappears around face and
anterior trunk by around 28
weeks
• Term infants may have
a few patches over
shoulders
• Examine on the upper
and lower areas of the
infant’s back

33. Physical Criteria
– Plantar Creases (-1 to 4)
• The first appearance of a crease appears
on the anterior sole at the ball of the foot.
This may be related to foot flexion in
utero, but is contributed to by
dehydration of the skin
• Appears by 28-30 weeks and cover the
anterior portion of the plantar surface of
the foot
• Extend toward the heel as gestational age
increases
• After 12 hours sole creases are not valid
indicator of gestational age due to drying
of the skin

34. Physical Criteria
– Breast Bud (-1 to 4)
• Breast bud consists of breast tissue
that is stimulated to grow by
maternal estrogens and fatty
tissue, which is dependent upon
fetal nutritional status
• Note the size of the areola and the
presence or absence of stippling.
Next, palpate the breast tissue
beneath the skin by holding it
between thumb and forefinger,
estimate its diameter in
millimeters

35. Physical Criteria
–Ear Cartilage and Eyelids (-1 to 4)
• The pinna of the fetal ear changes its
configuration and increases in
cartilage content as maturation
progresses.
• Assessment includes:
1. palpation for cartilage thickness and
2. folding the pinna forward towards
the face and releasing it
• In very premature infants, the
pinnae may remain folded when
released. In such infants, the
examiner notes the state of eyelid
development as an additional
indicator of fetal maturation

36. Physical Criteria
– Male Genitals (-1 to 4)
• Testicles found inside the rugated
zone are considered descended
• In extreme prematurity, the scrotum
is flat and smooth
• At term to post-term, the scrotum
may become pendulous and may
actually touch the mattress when the
infant lies supine
• In true crptorchidism, the scrotum on
the affected side appears
uninhabited, hypoplastic and with
underdeveloped rugae. In such cases,
the normal side should be scored, or if
bilateral, a score similar to that
obtained for the other maturational
criteria should be assigned

37. Physical Criteria
– Female Genitals (-1 to 4)
• To examine the infant
female, the hips should be
only partially abducted (45°
from the horizontal with
infant lying supine)
• Exaggerated adbuction may
cause the clitoris and labia
minora to appear more
prominent, whereas
adduction may cause the
labia majora to cover over
them

39. MATURITY SCORE
SCORE WEEKS
-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 44

41. THANK YOU