The document summarizes the Ballard score, which assesses gestational age in newborns based on their physical and neurological maturity. It describes six physical signs and six neurological signs that are observed and scored, with the total score corresponding to a gestational age between 20-44 weeks. Each sign is described in detail, outlining what is observed at different stages of maturity from preterm to full term. A video demonstration is provided for some of the neurological tests.

1. Ballard score
By
Ms.ULFAT AMIN
Tutor SMMCNMT

2. INTRODUCTION
• A frequently used method of determining gestational
age is the New Ballard Scale (NBS) by Ballard,
Khoury, Wedig, et al (1991).
• This scale, assesses six external physical and six
neuromuscular signs. Each sign has a number score,
and the cumulative score correlates with a maturity
rating of 20 to 44 weeks of gestation.

4. NEURO MUSCULAR
MATURITY

5. 1.POSTURE:
• Observe posture with infant not crying and in supine
position.
• Arms and legs are extended in preterms, while full
flexion of arms and legs is seen in term babies.
• Term baby has universal flexion (full flexion of arms
and legs); very preterm baby of 28 weeks or less will
have less flexor tone, and thus both upper and lower
limbs remain extended.

6. 1.POSTURE:
• By around 32 weeks, baby has flexion of lower limbs
but upper limbs still remain largely extended.
• By 36 weeks, both upper and lower limbs have less
flexor tone, almost like a term baby.

7. 1.POSTURE:

8. 2. SQUARE WINDOW TEST:
• Baby's hand is flexed on the forearm between the thumb
and index finger of the examiner with reasonable
pressure.
• Measure the angle between the hypothenar eminence
and the ventral aspect of the forearm.
• In full-term babies, the hypothenar eminence touches
the fore arm and hence the angle is nearly zero.
• In the extreme preterm, it is less malleable, and the
angle may be as much as 90°

10. 3.ARM RECOIL
• Keep the infant in the supine position; flex the fore arms for
5 sec, then fully extend it by pulling on the hands, and then
release. The sign is fully positive if the arms return briskly to
full flexion (i.e., in full-term babies, the arm recoils fully,
which means the angle that forearm makes with the arm
will be less than 90°).
• If the arms return to in complete flexion or the response is
sluggish, it is graded accordingly as per chart. They will
remain extended without recoiling in extreme pre-terms.
• https://www.youtube.com/watch?v=97I03A8eg_Y

12. 4. POPLITEAL ANGLE:
• Keep the infant supine and the pelvis flat on the examining
couch. Hold the thigh in the knee-chest position using the
left index finger and thumb to support the knee. Extend
the leg by gentle pressure from your right index finger
behind the ankle and measure the angle.
• Compare angle with the standard charts.
• In term babies, the angle is less than 90°.
• In extreme preterm babies, it may be as much as 180
• https://youtu.be/zCcoGGzacUk

14. 5. SCARF SIGN:
• With the infant in supine position, take the infant's
hand and try to put it across the chest as far as possible
towards the opposite shoulder.
• This manoeuvre will need lifting the elbow across the
body. See how far the elbow goes across and grade it as
per chart. Elbow will not cross the midline in term
babies

15. • 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)
– https://youtu.be/Lx_4DglwmIE

17. 6. HEEL TO EAR:
• With the infant lying supine, pull the infant's foot as
near to the head as it will go without forcing it.
Observe the distance between the foot and the
head as well as the degree of extension at the knee.

18. • 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)
–https://youtu.be/TpKAGbj-H3w

20. PHYSICAL MATURITY

21. 1. SKIN:

22. • 2. LANUGO:
• Fine hair covering the body of the fetus.
• 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.

24. 3. PLANTAR SURFACE:
• 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)

26. 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.

28. 5. EYE / EAR:
• Increasing maturity  Increasing cartilage content of ear.
• 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.

30. 6. GENITALS: (MALE)
• Fetal testicles begin their descent from the peritoneal cavity
into the scrotal sack at approximately 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. Concurrently, the scrotal skin thickens and develops
deeper and more numerous rugae.

31. 6. GENITALS: (MALE)

32. 6. GENITALS: (FEMALE)
• In extreme prematurity, the labia are flat and the clitoris is
very prominent and may resemble the male phallus.
• As maturation progresses, the clitoris becomes less
prominent and labia minora become more prominent.
• Near term, both clitoris and labia minora recede and are
eventually enveloped by the enlarging labia majora.

33. 6. GENITALS: (FEMALE)
• Hips should be only partially abducted, i.e., to
approximately 45° from the horizontal with the infant lying
supine.
• Exaggerated abduction may cause the clitoris and labia
minora to appear more prominent, whereas adduction may
cause the labia majora to cover over them.

35. Thank you