The document describes the Ballard Scale for assessing gestational age in newborns. The Ballard Scale evaluates both neuromuscular maturity (through tests of posture, arm recoil, etc.) and physical maturity (examining skin, lanugo, genitals). Scores on the scale range from -10 to 50. The scale is more accurate than the original Ballard Scale, with a margin of error of +/- 2 weeks compared to the actual gestational age. The document provides detailed descriptions of the assessments used in the Ballard Scale.

1. Assessment of
gestational age
BALLARD SCALE
ANJU KUMAWAT

2. Introduction
• Gestational age is the estimated age of a fetus expressed in
weeks, calculated from the first day of the last menstruation
period.
• Based on gestational age, each neonate is classified as-
• Pre term- <37 weeks
• Term- 39 to 41 weeks
• Post term- >42 weeks

3. • Gestational age can be assessed by three methods-
• 1. Menstruation history
• 2. Prenatal ultrasonography
• 3. Postnatal maturational examination

4. • Assessment of newborn can be divided into 4
phases:
• 1. Initial assessment
• 2. Transitional assessment
• 3. Gestational age assessment
• 4. Systematic physical examination

5. Ballard Scale
• A method to determine the gestational age is New Ballard
Scale(NBS). It was proposed by Dr. Jenne L Ballard in
1991. NBS assesses 6 external physical and 6
neuromuscular signs of maturity. Assessment of
gestational age from 20 to 44 weeks Scores range from
-10 to +50 Optimal time for assessment if from birth to
90 hours

6. Simple examination to assess Gestational
age Accurate to +/- 2 weeks
Dr. Jeanne L Ballard

7. • Comparison : Original & New
• Scores ranged from 5 to 50
26-44 wks
-10 to 50
20-44 wk
• Score starts with 0 Starts with -1
• Inaccurate in extremely preterm More accurate

8. • Comparison : Original & New
• Optimal age for maturational
assessment:
Btwn 30 and 42 hours of age. Birth to 96 hours
(Validated upto
7th Post natal
day in Mod
Preterms)
• Eyes: not included Included

9. • Takes in to account 2 things:
• 1. Neuromuscular maturity
• 2.Physical maturity
1. Posture
2. Square Window Test
3. Arm recoil
4. Popliteal angle
5. Scarf Sign
6. Heal to ear test
1. Skin
2. Lanugo
3. Plantar surface
4. Breast
5. Eye/Ears
6. Genitals
Neurological signs are more reliable than physical

10. • NEURO MUSCULAR MATURITY:
As gestational age progresses
Brain growth progresses
Neuromuscular maturity progresses

11. Neuro muscular maturity
• Posture
• Square window
• Arm recoil
• Popliteal angle
• Scarf sign
• Heel to ear

12. Neuro muscular maturity

13. • NEURO MUSCULAR MATURITY:
• 1.POSTURE: (AT REST)
• As maturation progresses  increasing passive
flexor tone
• Increasing passive flexor tone -centripetal direction.
• Lower extremities slightly ahead of upper
extremities (caudo cephalad)

14. • NEURO MUSCULAR MATURITY:
• 1.POSTURE:

15. POSTURE:
• Observe in the supine
position at rest
• Score is assigned
based on the degree of
flexion of arms, knees
and hips
• Increased flexion and
hip adduction with
increased gestational
age

16. • NEURO MUSCULAR MATURITY: SQUARE WINDOW TEST:
• Tests wrist flexibility &/or resistance to extensor
stretch.
• At term and post term, the infant has maximum
passive Flexor tone and minimum passive Extensor
tone.
• Infants hand is flexed on the forearm between the
thumb and index finger of the examiner. Apply
enough pressure to get full flexion without rotating
the wrist. Angle between the forearm and the palm
is measured.

18. • NEURO MUSCULAR MATURITY: ARM RECOIL:
• Focuses on Passive Flexor Tone of biceps muscle
• Briefly flex the elbow extend briefly Release
• This maneuver focuses on passive flexor tone of the
biceps muscle by measuring the angle of recoil following
very brief extension of the upper extremity. Flex the
neonates arms for 5 seconds while in the supine position.
Fully extend the arms by pulling on the hands and release
The degree of arm flexion and strength of recoil are
measured. Full term can flex hand completely up to face.

20. • NEURO MUSCULAR MATURITY: POPLITEAL ANGLE:
• This maneuver assesses maturation of passive flexor
tone about the knee joint by testing for resistance
to extension of the lower extremity.
• Place infant in supine position with the pelvis on the
mattress. Using the thumb and index finger of one
hand, examiner holds the knee adjacent to the chest
and abdomen. Gently extend the leg with the index
finger. Look at the angle between the lower leg,
thigh and posterior knee.

22. • NEURO MUSCULAR MATURITY: SCARF SIGN:
• Tests the passive tone of the flexors about the
shoulder girdle.
• The point on the chest to which the elbow moves easily
prior to significant resistance is noted.
• Landmarks noted in order of increasing maturity:
– Full scarf at the level of the neck (-1)
– Contralateral axillary line (0)
– Contralateral nipple line (1)
– Xyphoid process (2)
– Ipsilateral nipple line (3)
– ipsilateral axillary line (4)

23. Contd…
Place infant in supine position with head in mid-line
position. Grasp the infants hand and pull the arm across the
chest and around the neck. Look at the relationship of
elbow to mid-line of body when arm pulls across the chest.

25. • NEURO MUSCULAR MATURITY: HEEL TO EAR:
• Measures passive flexor tone about the pelvic girdle
by testing for passive flexion or resistance to
extension of posterior hip flexor muscles.
• Place the infant supine with pelvis flat on table. Grasp one foot with thumb and index finger
and draw foot as near to head as possible. Note the distance between the foot and head as
well as degree of knee extension

26. Contd….
• Note location of heel where significant resistance+
• Landmarks noted in order of increasing maturity
include resistance felt when the heel is at or near:
– ear (-1)
– nose (0)
– chin level (1)
– nipple line (2)
– umbilical area (3)
– femoral crease (4)

28. PHYSICAL MATURITY
• Skin
• Lanugo
• Plantar surface
• Breast
• Eye/ear
• Genitalia

31. • PHYSICAL MATURITY:
• 1. SKIN:
Less transparent and tougher with increasing gestational
age
36-37 weeks loses transparency and underlying vessels are
No longer visible increasing gestational age the veins
become less viable and increasing subcutaneous tissue

33. • PHYSICAL MATURITY:
• 2. LANUGO:
• Fine downy hair covering fetus from 20-28 weeks. Disappears around face and anterior
trunk ~28 weeks. Term infants may have a few patches over shoulders
• In extreme immaturity, the skin lacks any lanugo.
• Begins to appear at approximately 24th to 25th week.
• Abundant, especially across the shoulders and upper back
by the 28th week of gestation.
• At term, most of the fetal back is devoid of lanugo.

35. • PHYSICAL MATURITY: PLANTAR SURFACE:
28-30 weeks appear and cover the anterior portion of the
plantar surface of the foot
Extend toward the heel as increases gestational age
After 12 hours sole creases are not valid indicator of
gestational age due to drying of the skin
• Very premature  no detectable foot creases.
• Measure the foot length or heel-toe distance.
• Heel-toe distances:
– less than 40 mm  (-2)
– between 40 and 50 mm  (-1)

37. • PHYSICAL MATURITY:
• 4. BREAST:
• The breast bud consists of:
– breast tissue that is stimulated to grow by maternal estrogens
– fatty tissue which is dependent upon fetal nutritional status.
Areola is raised by 34 weeks
A 1-2 mm nodule of breast tissue is palpable by 36 weeks
By 40 weeks the nodule is 10mm

39. • PHYSICAL MATURITY:
• 5. EYE / EAR:
• Increasing maturity  Increasing cartilage content of ear.
Lids are open and complete eyelashes develops at term
Incurving of the upper pinna begins by 34 weeks gestation and extend entire lobe by 40 weeks
Before 34 weeks, pinna has very little cartilage (Stays folded on itself)
At 36 weeks, there is some cartilage and will spring back
• In very premature infants, the pinnae may remain folded
when released. In such infants, state of eyelid development
is an additional indicator of fetal maturation.

41. • PHYSICAL MATURITY:
• 6. GENITALS: (MALE)
• Fetal testicles begin their descent from the peritoneal cavity
into the scrotal sac at approximately 28 -30th week of
gestation.
• The left testicle precedes the right and usually enters the
scrotum during the 32nd week.
• Both testicles are usually palpable in the upper to lower
inguinal canals by the end of the 33rd to 34th weeks of
gestation.
At 37 weeks, testes can be palpated high in scrotum
At 40 weeks, testes are completely descended and covered with rugae
As gestation progresses, scrotum becomes more pendulous
• Concurrently, the scrotal skin thickens and develops deeper and
more numerous rugae.

42. • PHYSICAL MATURITY:GENITALS: (MALE)

43. • PHYSICAL MATURITY: GENITALS- FEMALE
• In extreme prematurity, the labia are flat and the clitoris is
very prominent.
• As maturation progresses, the clitoris becomes less
prominent and labia minora become more prominent.
• By 40 weeks, fat deposits have increased in size in labia
majora so labia minora are completely covered, both clitoris
and labia minora recede and are eventually enveloped by
the enlarging labia majora.