Neonatal Gestational Age

Assessment
• The physical maturity part of the examination
should be done in the first two hours of birth

• The neuromuscular maturity examination

should be completed with 24 hours after
delivery

• Derived to look at various stages in an infants

gestational maturity and observe how physical
characteristics change with gestational age

• Neonates who are more physically mature

normally have higher scores than premature Neuromuscular Maturity Criteria
infants
• Posture & Tone
• Points are awarded in each area -2 for
• Square Window

• Arm Recoil

• Popliteal Angle

• Scarf Sign

• Heel to Ear

Posture and Tone

• Total body muscle tone is reflected in the
infant's preferred posture at rest and resistance
to stretch of individual muscle groups.

extreme prematurity to 5 for postmature • Observe in the supine position at rest

infants • Score is assigned based on the degree of
flexion of arms, knees and hips

• Increased flexion and hip adduction with

increased gestational age

- The more mature an infant is the greater their

tone will be
- A more flexed position indicated greater tone
 Arm Recoil
• Posture & Tone
• Measures the angle of recoil following a brief
• Before 30 weeks-hypotonic, little or no flexion
extension of the upper extremity
seen
• For 5 seconds flex the arms while infant is in
• 30-38 weeks-varying degrees of flexed
the supine position, pulling the hands fully
extremities
extend the arms to the side, then release-
• 38-42 weeks-may appear hypertonic measure the degree of arm flexion & strength
(recoil)
Square Window
• Before 28 weeks-no recoil
• Wrist flexibility and/or resistance to extensor
stretching resulting in angle or flexion at wrist • 28-32 weeks-slight recoil

• Infant’s hand is flexed on the forearm • 32-36 weeks-recoil does not pass 90 degrees
between the thumb and index finger of the • 36-40 weeks-recoils to 90 degrees
examiner
• After 40 weeks-rapid full recoil
• Apply enough pressure to get full flexion
without rotating the wrist

• Angle between the forearm and the palm is

measured.

• Before 26 weeks-wrist can’t be flexed more

than 90 degrees

• Before 30 weeks-wrist can be flexed no more

than 90 degrees

• 36-38 weeks-wrist can be flexed no more than

90 degrees
Popliteal Angle
- Assesses maturation of passive flexor tone
about the knee joint by testing resistance to
extension of the leg
• 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.

- Place infant in supine position with the pelvis • Look at the relationship of elbow to mid-line
on the mattress of body when arm pulls across the chest

- 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.
The angle decreases with advancing
gestational age
• Before 26 weeks-angle 180 degrees
• Before 28 weeks-elbow passes torso
• 28-34 weeks-elbow passes opposite nipple
line
• 34-36 weeks-elbow can be pulled past
midline, no resistance
• 36-40 weeks-elbow to midline with some
resistance
• After 40 weeks-doesn’t reach midline

• 26-28 weeks-angle 160 degrees

• 28-32 weeks-angle 140 degrees

• 32-36 weeks angle 120 degrees

Scarf Sign
• Tests the passive tone of the flexors about the
shoulder girdle

• Increased resistance to this maneuver with

advancing gestational age

Physical Maturity Criteria
• Skin
• Lanugo
• Plantar Surface
• Breast
• Eye/Ear
• Genitalia- Male
• Genitalia- Female
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.
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.
Plantar Surface
• The plantar surface is assessed for 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. this may be related
to foot flexion in utero, but is contributed to by
dehydration of the skin.
Breast
• The breast bud consists of breast tissue that is
stimulated to grow by maternal estrogens and
fatty tissue which is dependent upon fetal
nutritional status. the examiner notes the size
of the areola and the presence or absence of
stippling (created by the developing papillae of
Montgomery).
• The examiner palpates the breast tissue
beneath the skin by holding it between thumb
and forefinger, estimating its diameter in
millimeters.
Ear
• The pinna of the fetal ear changes it
configuration and increases in cartilage content
as maturation progresses. Assessment includes
palpation for cartilage thickness, then folding
the pinna forward toward the face and
releasing it.
• The examiner notes the rapidity with which
the folded pinna snaps back away from the face
when released.
Eye
• The examiner places thumb and forefinger on
the upper and lower lids, gently moving them
apart to separate them.

• The extremely immature infant will have

tightly fused eyelids, i.e., the examiner will not
be able to separate either palpebral fissure with
gentle traction.

Genitalia-Male
• 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
• testicles are usually palpable in the upper to
lower inguinal canals by the end of the 33rd to
34th weeks of gestation.
• The scrotal skin thickens and develops deeper
and more numerous rugae.
• The New Ballard Score allows scores of -1 for
the criteria, hence making negative scores
possible. The possible scores then range from -
10 to 50, the gestational range extending up to
20 weeks. (A simple formula to come directly to
the age from the Ballard Score is Age=((2*score)
+120)) / 5

• For simple calculation, the scores of both

neuromuscular and physical maturity are
added and are corresponded to the maturity
Genitalia- Female rating

• To examine the infant female, the hips should • Mturity rating:

be only partially abducted, i.e., to Score/weeks:
approximately 45° from the horizontal with the
infant lying supine. (-10/20),(5/22),(0/24),(5/26),(10/28),

• Exaggerated abduction may cause the clitoris (15/30),(20/32),(25/34),(30/36),(35/38),

and labia minora to appear more prominent,
(40/40),(45/42),(50/44).
whereas adduction may cause the labia majora
to cover over them.

• Nearing term, both clitoris and labia minora

recede and are eventually enveloped by the
enlarging labia majora.