BALLARD SCORE

Simple examination to assess Gestational age

Accurate to +/- 2 weeks
 • Comparison : Original & New

• Scores ranged from 5 to 50 -10 to 50

26-44 wks 20-44 wk

• Score starts with 0 Starts with -1

• Inaccurate in extremely preterm More accurate

• Comparison : Original & New
• Optimal age for maturational
assessment:
Btwn 30 and 42 hours of
age. Birth to 96 hours
(Validated upto
7th PND in Mod
Preterms)

• Eyes: not included Included

• Takes in to account 2 things:
• 1. Neuromuscular maturity
1. Posture
2. Square Window Test
3. Arm recoil
4. Popliteal angle
5. Scarf Sign
6. Heal to ear test

• 2.Physical maturity

1. Skin 4. Breast
2. Lanugo 5. Eye/Ears
3. Plantar surface 6. Genitals

Neurological signs are more reliable than physical

• NEURO MUSCULAR MATURITY:

As gestational age progresses

Brain growth progresses

Neuromuscular maturity
progresses
• 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)
• NEURO MUSCULAR MATURITY:
• 1.POSTURE:
• NEURO MUSCULAR MATURITY:
• 1.POSTURE:
• NEURO MUSCULAR MATURITY:
• 2. 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.
• NEURO MUSCULAR MATURITY:
• 3.ARM RECOIL:
• Focuses on Passive Flexor Tone of biceps muscle
• Briefly flex the elbow  extend briefly  Release
• NEURO MUSCULAR MATURITY:
• 4. POPLITEAL ANGLE:
• This maneuver assesses maturation of passive flexor
tone about the knee joint by testing for resistance
to extension of the lower extremity.
• NEURO MUSCULAR MATURITY:
• 5. 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.
• NEURO MUSCULAR MATURITY:
• 5. SCARF SIGN:
• 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)
• NEURO MUSCULAR MATURITY:
• 6. 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.
• NEURO MUSCULAR MATURITY:
• 6. HEEL TO EAR:
• 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)
• PHYSICAL MATURITY:
• 1. SKIN:
• PHYSICAL MATURITY:
• 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.
• PHYSICAL MATURITY:
• 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)
• 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.
• PHYSICAL MATURITY:
• 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.
• PHYSICAL MATURITY:
• 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.
• PHYSICAL MATURITY:
• 6. GENITALS: (MALE)
• PHYSICAL MATURITY:
• 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.
• Nearing term, both clitoris and labia minora recede and are
eventually enveloped by the enlarging labia majora.
• PHYSICAL MATURITY:
• 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.