GUAGUA NATIONAL COLLEGES

Guagua, Pampanga
COLLEGE OF ALLIED MEDICAL PROGRAMS

Ballard Score
(Physical Maturity)

SUBMITTED BY:

Canlas, Michaella M.

Cano, Gean B.

Guintu, Gwyneth L.

SUBMITTED TO:

Josefina V. Sioco, RN

Clinical Instructo
 Physical Maturity Score
Sign -1 0 1 2 3 4 5
smooth superficial parchment,
Gelatinous, cracking, leathery,
Stick, friable, pink, peeling &/or deep
Skin red, pale areas, cracked,
transparent visible rash, few cracking,
translucent rare veins wrinkled
veins veins no vessels
Lanugo none Sparse Abundant Thinning Bald areas Mostly bald
heel-toe anterior creases
Plantar >50 mm faint red creases
40-50mm:-1 transverse over entire
Surface no crease marks ant. 2/3
<40mm: -2 crease only sole
raised
stippled full areola
barely flat areola areola
Breast imperceptable areola 5-10 mm
perceptable no bud 3-4 mm
1-2 mm bud bud
bud
sl. curved well-curved formed &
lids fused lids open thick
pinna; pinna; soft firm
Eye/Ear loosely: -1 pinna flat cartilage
soft; slow but ready instant
tightly: -2 stays folded ear stiff
recoil recoil recoil
testes in testes
scrotum testes testes
Genital scrotum flat, upper down,
empty, descending, pendulous,
(Male) smooth canal, good
faint rugae few rugae deep rugae
rare rugae rugaet
prominent majora & majora majora
clitoris prominent
Genitals clitoris & minora large, cover
prominent & & small
(Female) enlarging equally minora clitoris &
labia flat labia minora
minora prominent small minora

1. Skin
 Maturation of fetal skin involves the development of its intrinsic structures concurrent with the
gradual loss of its protective coating, the vernix caseosa. Hence, it thickens, dries, and becomes
wrinkled and/or peels, and may develop
a rash as fetal maturation progresses.
These phenomena may occur at varying
paces in individual fetuses depending in
part upon the maternal condition and the
intrauterine environment.
 Before the development of the 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 disappears toward the end of gestation. Figure 1.
  Meconium and its effects on fetal skin maturation
o At term and post-term, the fetus may expel meconium into the amniotic fluid. With this, it
adds an accelerating effect to the drying process - resulting in peeling, cracking,
dehydration, and imparting a parchment then leathery, appearance to the skin.
o For scoring purposes, the square which describes the infant's skin the most closely should
be selected.

PHYSICAL MATURITY SCORE SIGN

SIGN
-1 0 1 2 3 4 5 SCORE
smooth superficial
Sticky, gelatinous, cracking, parchment, leathery,
pink, peeling &/or
Skin friable, red, pale areas, deep cracking, cracked,
visible rash, few
transparent translucent  rare veins no vessels wrinkled
veins veins

Figure 2.

2. Lanugo
 Lanugo is the fine hair covering the body of the
fetus.
 In extreme immaturity, the skin lacks any lanugo. It
begins to appear at approximately the 24th to 25th
week and is usually abundant, especially across the
shoulders and upper back, by the 28th week of
gestation.
 Thinning occurs first over the lower back, wearing
away as the fetal body curves forward into its
mature, flexed position.
 Bald areas appear and become larger over the
lumbo-sacral area. At term, most of the fetal back is devoid of lanugo, i.e., the back is mostly bald.
Figure 3.
 Lanugo Contributing Factors
 o Variability in amount and location of lanugo at a given gestational age may be attributed into
familial or national traits and to certain hormonal, metabolic, and nutritional influences.
o For example, infants of diabetic mothers characteristically have abundant lanugo on their
pinnae and upper back until close to or beyond full-term gestation.
o When scoring for lanugo, the examiner selects the square that most closely describes the
relative amounts of lanugo on the upper and lower areas of the infant's back.

PHYSICAL MATURITY SCORE SIGN

N
-1 0 1 2 3 4 5 SCORE

  Lanugo      none      sparse   abundant thinning bald areas mostly bald          
 

Figure 4.

3. Plantar Surface
 This section pertains to the major foot creases on the sole of the foot. The first appearance of a
crease appears on the anterior sole at the ball of the foot, which may be related to foot flexion in
utero, but is contributed to by dehydration of the skin. Infants of non-white origin have been
reported to have fewer foot creases at birth. There is no known explanation for this.
 On the other hand, the reported acceleration of neuromuscular maturity in African American infants
usually compensates for this, resulting in a cancellation of the delayed foot crease effect. Hence,
there is usually no over- or under-estimation of gestational age due to the race when the total score
is performed.
 Figure 5.
 Plantar Surface Factors and Measurement
o Very premature and extremely immature infants have no detectable foot creases. To
further help define the gestational age of these infants, measuring the foot length or
heel-toe distance is helpful. T
o his is done by placing the infant's foot on a metric tape measure and noting the
distance from the back of the heel to the tip of the great toe. For heel-toe distances
less than 40 mm, a minus two score (-2) is assigned; for those between 40 and 50 mm,
a minus one score (-1) is assigned.

PHYSICAL MATURITY SCORE SIGN

SIGN
-1 0 1 2 3 4 5 SCORE
 heel-toe anterior creases
Plantar >50 mm faint red creases
40-50mm: -1 transverse over entire                      
Surface no  crease marks ant. 2/3
<40mm: -2 crease only sole

Figure 6.
6. Genitals-Male
Male Assessment using the Ballard Score
The fetal testicles begin their descent from the peritoneal cavity into the scrotal sack at
approximately the 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.
Assessment of Fetal Development of the Male
Testicles found inside the rugated zone are considered descended. In extreme prematurity the
scrotum is flat, smooth and appears sexually undifferentiated. At term to post-term, the scrotum
may become pendulous and may actually touch the mattress when the infant lies supine. Note: In
true cryptorchidism, the scrotum on the affected side appears uninhabited, hypoplastic and with
underdeveloped rugae compared to the normal side, or, for a given gestation, when bilateral. In
such a case, the normal side should be scored, or if bilateral, a score similar to that obtained for
the other maturational criteria should be assigned.
Male Assessment Scoring

PHYSICAL MATURITY SCORE SIGN

SIGN
-1 0 1 2 3 4 5 SCORE
testes in
scrotum testes
scrotum upper testes testes
Genitals empty, down,
Flat, canal, descending, pendulous,deep             
(Male) faint good
smooth rare few rugae rugae
rugae rugae
rugae

7. Genitals – Female
Female Assessment using the Ballard Score
To examine the infant female, the 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.
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. Nearing term, both clitoris and labia minora recede and are eventually
enveloped by the enlarging labia majora.
Assessment of Fetal Development of the Female
The labia majora contain fat and their size are affected by intrauterine nutrition. Over-nutrition
may result in large labia majora earlier in gestation, whereas under-nutrition, as in intrauterine
growth retardation or post-maturity, may result in small labia majora with relatively prominent
clitoris and labia minora late into gestation. These findings should be reported as observed, since
a lower score on this item in the chronically stressed or growth retarded fetus may be counter-
balanced by a higher score on certain neuro-muscular items.
Female Assessment Scoring

PHYSICAL MATURITY SCORE SIGN

SIGN
-1 0 1 2 3 4 5 SCORE
prominent prominent Majora & majora
Genitals clitoris clitoris & clitoris & minora large, majora cover
prominent                 
(Female) & labia flat small labiaenlarging equally minora clitoris & minora
minora minora prominent small

Gestational Age Assessment means figuring out the number of weeks of pregnancy. A full-term
pregnancy is usually 40 weeks. It is important to assess if gestational age is uncertain or if the
baby is smaller or larger than expected.
The Ballard score is commonly used to determine gestational age. Here’s how it works:
 Scores are given for 6 physical and 6 nerve and muscle development (neuromuscular)
signs of maturity. The scores for each may range from -1 to 5.
 The scores are added together to determine the baby’s gestational age. The total score
may range from -10 to 50.
 Premature babies have low scores. Babies born late have high scores.

Add up the Neuromuscular Score and the Physical Score and with the Total, It can now
estimate the Maturity Rating
Maturity of Neonate
 Premature: < 34 weeks
 Late Pre-term: 34-37 weeks
 Early Term: 37-38 weeks
 Full Term: 39-40 weeks
 Late Term: 41-42 weeks
  Post Term/ Postmature - >42 weeks

REFERENCE
Ballard, J. L., MD. (n.d.). Ballard Score Training - Physical Maturity - Ballard Score.

https://www.ballardscore.com/CatalogView/Category/physical-maturity