gestational age assessment handout color 6 per pg

The S.T.A.B.L.E. Program: GA
Assessment
(c) Kristine A. Karlsen 2006. Handout
reproducible for educational purposes. 1
© K. Karlsen 2006
Kristine A. Karlsen MSN, RNC, NNP
Author
National Program Director, Founder
The S.T.A.B.L.E. Program
Park City, Utah

Kristine A. Karlsen
Kristine A. Karlsen
MSN, RNC, NNP
MSN, RNC, NNP
Author
Author
National Program Director, Founder
National Program Director, Founder
The S.T.A.B.L.E. Program
The S.T.A.B.L.E. Program
Park City, Utah
Park City, Utah


PowerPoint
®
Design
Mary Puchalski MS, RNC, APN/CNS
Lombard, Illinois

Medical Illustrations
John Gibb MA
PowerPoint
PowerPoint
®
®
Design
Design
Mary Puchalski
Mary Puchalski
MS, RNC, APN/CNS
MS, RNC, APN/CNS
Lombard, Illinois
Lombard, Illinois


Medical Illustrations
Medical Illustrations
John Gibb MA
John Gibb MA
Gestational Age
Assessment of the Newborn
Gestational Age
Gestational Age
Assessment of the Newborn
Assessment of the Newborn
© K. Karlsen 2006
Ballard
Gestational
Age

Assessment
Ballard
Gestational
Age
Assessment
Adapted from:
Adapted from:
Ballard et al. (1991)
Ballard et al. (1991)
J
J
Pediatr
Pediatr
.,
.,
119(3): 417
119(3): 417
-
-
423.
423.
Physical Maturity
Physical Maturity
Female
Female
Genitals
Genitals
Male
Male
Genitals

Genitals
Eyes / ears
Eyes / ears
Breast
Breast
Plantar
Plantar
surface
surface
Lanugo
Lanugo
Skin
Skin
Thick cartilage
Ear stiff
Formed and
firm
Instant recoil
Well-curved
pinna
Soft but ready
recoil
Slightly
curved pinna
Soft slow recoil
Lids open
Pinna flat
Stays folded
Lids fused:
Loosely: -1

Tightly: -2
Testes
pendulous
Deep rugae
Testes down
Good rugae
Testes
descending
Few rugae
Testes in upper
canal
Rare rugae
Scrotum empty
Faint rugae
Scrotum flat,
smooth
Majora cover
clitoris and
minora
Majora large
Minora small
Majora and
minora equally
prominent
Prominent
clitoris
Enlarging
minora
Prominent
clitoris

Small labia
minora
Clitoris
prominent
Labia flat
Full areola
5-10 mm bud
Raised areola
3-4 mm bud
Stippled areola
1-2 mm bud
Flat areola no
bud
Barely
perceptible
Imperceptible
Creases over
entire sole
Creases
anterior 2/3
Anterior
transverse
crease only
Faint red marks
Heel- toe
> 50 mm
No crease
Heel- toe
40-50 mm
< 40 = -2

Mostly baldBald Areas
Thinning
Lanugo
Abundant
lanugo
Sparse lanugoNo lanugo
Parchment
Deep cracking
No vessels
4
4
Cracking
Pale areas
Rare veins
3
3
Leathery
Cracked
Wrinkled
5
5
Superficial
peeling and/or
rash
Few veins
Smooth pink
Visible veins
Gelatinous
Red
Translucent

Sticky
Friable
Transparent
2
2
1
1
0
0
-
-
1
1
Neuromuscular Maturity
Neuromuscular Maturity
Heel to ear
Heel to ear
Scarf sign
Scarf sign
Popliteal
Popliteal
angle
angle
Arm recoil
Arm recoil
Square
Square
window
window
(wrist)

(wrist)
Posture
Posture
© K. Karlsen 2006
Ballard
Gestational
Age
Assessment
Ballard
Gestational
Age
Assessment
Neuromuscular illustrations were adapted
Neuromuscular illustrations were adapted
with permission of Dr. Ballard
with permission of Dr. Ballard
A detailed monograph and
explanation about how to
perform the Ballard exam
(written by Dr. Ballard),
may be found at
www.BallardScore.com
A detailed monograph and
A detailed monograph and
explanation about how to
explanation about how to
perform the Ballard exam
perform the Ballard exam
(written by Dr. Ballard),
(written by Dr. Ballard),

may be found at
may be found at
www.BallardScore.com
www.BallardScore.com
Adapted from:
Adapted from:
Ballard et al. (1991)
Ballard et al. (1991)
J
J
Pediatr
Pediatr
.,
.,
119(3): 417
119(3): 417
-
-
423.
423.
© K. Karlsen 2006
Principles of Exam
Principles of Exam
Timing
Timing
Most reliable if performed by 12 hours of life
Most reliable if performed by 12 hours of life
Keep infant warm
Keep infant warm
© K. Karlsen 2006

Ballard Exam  Physical Maturity
Ballard Exam  Physical Maturity
Female
Female
Genitals
Genitals
Male
Male
Genitals
Genitals
Eyes /
Eyes /
ears
ears
Breast
Breast
Plantar
Plantar
surface
surface
Lanugo
Lanugo
Skin
Skin
Thick
cartilage
Ear stiff
Formed
and firm
Instant recoil

Well-curved
pinna
Soft but
ready recoil
Slightly
curved pinna
Soft slow
recoil
Lids open
Pinna flat
Stays folded
Lids fused:
Loosely: -1
Tightly: -2
Testes
pendulous
Deep rugae
Testes down
Good rugae
Testes
descending
Few rugae
Testes in
upper canal
Rare rugae
Scrotum
empty
Faint rugae
Scrotum
flat, smooth

Majora cover
clitoris and
minora
Majora large
Minora small
Majora and
minora
equally
prominent
Prominent
clitoris
Enlarging
minora
Prominent
clitoris
Small labia
minora
Clitoris
prominent
Labia flat
Full areola
5-10 mm bud
Raised
areola
3-4 mm bud
Stippled
areola
1-2 mm bud
Flat areola
no bud

Barely
perceptible
Im-
perceptible
Creases over
entire sole
Creases
anterior 2/3
Anterior
transverse
crease only
Faint red
marks
Heel- toe
> 50 mm
No crease
Heel- toe
40-50 mm
<40 = 2
Mostly baldBald areas
Thinning
Lanugo
Abundant
lanugo
Sparse
lanugo
No lanugo
Parchment
Deep
cracking

No vessels
4
4
Cracking
Pale areas
Rare veins
3
3
Leathery
Cracked
Wrinkled
5
5
Superficial
peeling
and/or rash
Few veins
Smooth pink
Visible veins
Gelatinous
Red
Translucent
Sticky
Friable
Transparent
2
2
1
1
0

0
-
-
1
1
© K. Karlsen 2006
Skin
Skin
0
1
-
-
1
1
Parchment
Deep
cracking
No vessels
4
4
Cracking
Pale areas
Rare veins
3
3
Leathery
Cracked
Wrinkled
5
5

Superficial
peeling
and/or rash
Few veins
Smooth
pink
Visible
veins
Gelatinous
Red
Translucent
Sticky
Friable
Transparent
2
2
1
1
0
0
-
-
1
1
The S.T.A.B.L.E. Program: GA
Assessment
(c) Kristine A. Karlsen 2006. Handout
reproducible for educational purposes. 2
© K. Karlsen 2006
Skin

Skin
2
2
3
3
Parchment
Deep
cracking
No vessels
4
4
Cracking
Pale areas
Rare veins
3
3
Leathery
Cracked
Wrinkled
5
5
Superficial
peeling
and/or rash
Few veins
Smooth
pink
Visible
veins
Gelatinous

Red
Translucent
Sticky
Friable
Transparent
2
2
1
1
0
0
-
-
1
1
© K. Karlsen 2006
Skin
Skin
3
3
5
5
4
4
Parchment
Deep
cracking
No vessels
4
4

Cracking
Pale areas
Rare veins
3
3
Leathery
Cracked
Wrinkled
5
5
Superficial
peeling
and/or rash
Few veins
Smooth
pink
Visible
veins
Gelatinous
Red
Translucent
Sticky
Friable
Transparent
2
2
1
1
0
0

-
-
1
1
© K. Karlsen 2006
Lanugo
Lanugo
Mostly baldBald areasThinningAbundantSparseNo lanugo
4
4
3
3
2
2
1
1
0
0
-
-
1
1
Begins to appear 24
Begins to appear 24
–
–
25 weeks
25 weeks
Abundant across shoulders and upper back by 28 weeks
Abundant across shoulders and upper back by 28 weeks

With increasing gestation
With increasing gestation
Lower back area thins first
Lower back area thins first
Bald areas appear over
Bald areas appear over
lumbo
lumbo
-
-
sacral area
sacral area
Mostly bald by term
Mostly bald by term
Amount and location may vary with nutritional status,
Amount and location may vary with nutritional status,
ethnicity, hormonal and metabolic factors
ethnicity, hormonal and metabolic factors
© K. Karlsen 2006
Lanugo
Lanugo
-1
0
Mostly baldBald areasThinningAbundantSparseNo lanugo
4
4
3
3
2
2

1
1
0
0
-
-
1
1
© K. Karlsen 2006
Lanugo
Lanugo
Mostly baldBald areasThinningAbundantSparseNo lanugo
4
4
3
3
2
2
1
1
0
0
-
-
1
1
1
© K. Karlsen 2006
Lanugo
Lanugo

1
Mostly baldBald areasThinningAbundantSparseNo lanugo
4
4
3
3
2
2
1
1
0
0
-
-
1
1
The S.T.A.B.L.E. Program: GA
Assessment
(c) Kristine A. Karlsen 2006. Handout
reproducible for educational purposes. 3
© K. Karlsen 2006
Lanugo
Lanugo
4
2
Mostly baldBald areasThinningAbundantSparseNo lanugo
4
4
3
3

2
2
1
1
0
0
-
-
1
1
3
© K. Karlsen 2006
-1
1
Creases
over entire
sole
4
4
Creases
anterior 2/3
3
3
Anterior
transverse
crease only
Faint red
marks
> 50 mm
No crease

Heel–toe
40 – 50 mm
< 40 = – 2
2
2
1
1
0
0
-
-
1
1
0
Plantar Surface
Plantar Surface
© K. Karlsen 2006
Plantar Surface
Plantar Surface
2
4
Creases
over entire
sole
4
4
Creases
anterior 2/3
3
3

Anterior
transverse
crease only
Faint red
marks
> 50 mm
No crease
Heel–toe
40 – 50 mm
< 40 = – 2
2
2
1
1
0
0
-
-
1
1
3
© K. Karlsen 2006
Breast
Breast
-1
Full areola
5–10 mm
bud
4
4

Raised
areola
3–4 mm bud
3
3
Stippled
areola
1–2 mm bud
Flat areola
no bud
Barely
perceptible
Im-
perceptible
2
2
1
1
0
0
-
-
1
1
0 1
© K. Karlsen 2006
Breast
Breast
4
Full areola

5–10 mm
bud
4
4
Raised
areola
3–4 mm bud
3
3
Stippled
areola
1–2 mm bud
Flat areola
no bud
Barely
perceptible
Im-
perceptible
2
2
1
1
0
0
-
-
1
1
32
© K. Karlsen 2006

Eye and Ear
Eye and Ear
-2
Thick
cartilage
Ear stiff
4
4
Formed
and firm
Instant
recoil
3
3
Well-curved
pinna
Soft but
ready recoil
Slightly
curved pinna
Soft slow
recoil
Lids open
Pinna flat
Stays folded
Lids fused:
Loosely: -1
Tightly: -2
2
2

1
1
0
0
-
-
1
1
0
The S.T.A.B.L.E. Program: GA
Assessment
(c) Kristine A. Karlsen 2006. Handout
reproducible for educational purposes. 4
© K. Karlsen 2006
Eye and Ear
Eye and Ear
3 4
2
1
Thick
cartilage
Ear stiff
4
4
Formed
and firm
Instant
recoil
3
3

Well-curved
pinna
Soft but
ready recoil
Slightly
curved pinna
Soft slow
recoil
Lids open
Pinna flat
Stays folded
Lids fused:
Loosely: -1
Tightly: -2
2
2
1
1
0
0
-
-
1
1
© K. Karlsen 2006
Genitalia  Male
Genitalia  Male
0
1
Testes

pendulous
Deep rugae
4
4
Testes
down
Good rugae
3
3
Testes
descending
Few rugae
Testes in
upper canal
Rare rugae
Scrotum
empty
Faint rugae
Scrotum
flat, smooth
2
2
1
1
0
0
-
-
1
1

3
42
© K. Karlsen 2006
Genitalia
Genitalia
0
3
4
Majora
cover
clitoris and
minora
Majora
large
Minora
small
Majora and
minora
equally
prominent
Prominent
clitoris
Enlarging
minora
Prominent
clitoris
Small labia
minora
Clitoris
prominent

Labia flat
4
4
3
3
2
2
1
1
0
0
-
-
1
1
 Female
 Female
© K. Karlsen 2006
Heel to
Heel to
ear
ear
Scarf
Scarf
sign
sign
Popliteal
Popliteal
angle
angle

Arm
Arm
recoil
recoil
Square
Square
window
window
(wrist)
(wrist)
Posture
Posture
4
4
3
3
5
5
2
2
1
1
0
0
-
-
1
1
Ballard Exam  Neuromuscular Maturity
Ballard Exam  Neuromuscular Maturity

© K. Karlsen 2006
Principles of Neuromuscular Exam
Principles of Neuromuscular Exam
Positioning
Positioning
Head midline
Head midline
Hips flat
Hips flat
Reliability of
Reliability of
exam altered by:
exam altered by:
Sedation
Sedation
Anesthesia
Anesthesia
Paralysis
Paralysis
Critically ill state
Critically ill state
Breech position
Breech position
!
!
Neuromuscular assessment may be too
stressful for premature and sick infants
 should be performed by skilled
neonatal ICU personnel once infant
stabilized and able to tolerate the exam

!
!
Neuromuscular assessment may be too
Neuromuscular assessment may be too
stressful for premature and sick infants
stressful for premature and sick infants


s
s
hould be performed by skilled
hould be performed by skilled
neonatal ICU personnel once infant
neonatal ICU personnel once infant
stabilized and able to tolerate the exam
stabilized and able to tolerate the exam
© K. Karlsen 2006
Posture
Posture
4
4
3
3
2
2
1
1
0
0
-

-
1
1
1
2
The S.T.A.B.L.E. Program: GA
Assessment
(c) Kristine A. Karlsen 2006. Handout
reproducible for educational purposes. 5
© K. Karlsen 2006
Posture
Posture
4
4
3
3
2
2
1
1
0
0
-
-
1
1
3
4
© K. Karlsen 2006
Square Window

Square Window
Assesses wrist flexibility and/or resistance to extensor
Assesses wrist flexibility and/or resistance to extensor
stretching at the wrist
stretching at the wrist
Press gently on knuckles to straighten fingers
Press gently on knuckles to straighten fingers
Apply gentle pressure on back of hand close to
Apply gentle pressure on back of hand close to
fingers
fingers


avoid wrist rotation
avoid wrist rotation
Stop pressing when resistance felt
Stop pressing when resistance felt
Angle
Angle
decreases
decreases
as gestational age
as gestational age
increases
increases
4
4
3
3
2

2
1
1
0
0
-
-
1
1
90
90


60
60


45
45


30
30


0
0


>90

>90


© K. Karlsen 2006
Square Window
Square Window
4
4
3
3
2
2
1
1
0
0
-
-
1
1
0
1
90
90


60
60



45
45


30
30


0
0


>90
>90


© K. Karlsen 2006
4
4
3
3
2
2
1
1
0
0
-
-
1

1
2
3 4
Square Window
Square Window
90
90


60
60


45
45


30
30


0
0


>90
>90


© K. Karlsen 2006

Arm Recoil
Arm Recoil
Tests for passive flexor tone of biceps muscle
Tests for passive flexor tone of biceps muscle
Test one arm at a time in order to avoid the Moro
Test one arm at a time in order to avoid the Moro
reflex
reflex
Supine position
Supine position
Hold infant
Hold infant
’
’
s hand
s hand
Briefly flex arm
Briefly flex arm


then momentarily extend arm and
then momentarily extend arm and
release hand
release hand
Scores based on angle of recoil when arms return
Scores based on angle of recoil when arms return
to flexion
to flexion
4
4

3
3
2
2
1
1
0
0
-
-
1
1
180
180


140
140
-
-
180
180


110
110
-
-
140
140



90
90
-
-
110
110


<90
<90


© K. Karlsen 2006
Arm Recoil
Arm Recoil
4
4
3
3
2
2
1
1
0
0
-
-
1

1
1 3
4
180
180


140
140
-
-
180
180


110
110
-
-
140
140


90
90
-
-
110
110



<90
<90


The S.T.A.B.L.E. Program: GA
Assessment
(c) Kristine A. Karlsen 2006. Handout
reproducible for educational purposes. 6
© K. Karlsen 2006
Assesses maturation of passive flexor tone about the
Assesses maturation of passive flexor tone about the
knee joint
knee joint
Refrain from touching hamstrings (the muscle group
Refrain from touching hamstrings (the muscle group
being tested) during maneuver
being tested) during maneuver
Thigh placed in knee
Thigh placed in knee
-
-
chest position with knee fully flexed
chest position with knee fully flexed
Allow infant to relax, then grasp foot at sides
Allow infant to relax, then grasp foot at sides
Extend leg until resistance is felt
Extend leg until resistance is felt
Estimate angle behind the knee
Estimate angle behind the knee

Measurement unreliable if frank breech in utero
Measurement unreliable if frank breech in utero
Popliteal Angle
Popliteal Angle
4
4
5
5
3
3
2
2
1
1
0
0
-
-
1
1
180
180


160
160


140
140



120
120


<90
<90


100
100


90
90


© K. Karlsen 2006
0
1
Popliteal Angle
Popliteal Angle
4
4
5
5
3
3
2

2
1
1
0
0
-
-
1
1
180
180


160
160


140
140


120
120


<90
<90


100

100


90
90


© K. Karlsen 2006
Popliteal Angle
Popliteal Angle
2
4
3
4
4
5
5
3
3
2
2
1
1
0
0
-
-
1
1
180

180


160
160


140
140


120
120


<90
<90


100
100


90
90


© K. Karlsen 2006
Scarf Sign
Scarf Sign

Tests passive tone of the posterior shoulder girdle
Tests passive tone of the posterior shoulder girdle
flexor muscles
flexor muscles
Supine position with head midline
Supine position with head midline
Hold infant
Hold infant
’
’
s hand across chest and use thumb of other
s hand across chest and use thumb of other
hand to gently push elbow across chest
hand to gently push elbow across chest
Or, gently pull arm across chest
Or, gently pull arm across chest
(shown in photos)
(shown in photos)
Stop when resistance is felt
Stop when resistance is felt
Scores based on position of elbow at landmarks
Scores based on position of elbow at landmarks
4
4
3
3
2
2
1
1

0
0
-
-
1
1
neck
neck
axillary line
axillary line
nipple line
nipple line
xyphoid
xyphoid
process
process
nipple line
nipple line
axillary line
axillary line
© K. Karlsen 2006
Scarf Sign
Scarf Sign
4
4
3
3
2
2
1

1
0
0
-
-
1
1
1
2
neck
neck
axillary line
axillary line
nipple line
nipple line
xyphoid
xyphoid
process
process
nipple line
nipple line
axillary line
axillary line
© K. Karlsen 2006
Scarf Sign
Scarf Sign
4
4
3
3

2
2
1
1
0
0
-
-
1
1
3
4
neck
neck
axillary line
axillary line
nipple line
nipple line
xyphoid
xyphoid
process
process
nipple line
nipple line
axillary line
axillary line
The S.T.A.B.L.E. Program: GA
Assessment
(c) Kristine A. Karlsen 2006. Handout
reproducible for educational purposes. 7

© K. Karlsen 2006
Heel-to-Ear
Heel-to-Ear
Tests for passive flexion or resistance to extension
Tests for passive flexion or resistance to extension
of posterior hip flexor muscles
of posterior hip flexor muscles
Refrain from touching gluteus muscle (the muscle group
Refrain from touching gluteus muscle (the muscle group
being tested) during maneuver
being tested) during maneuver
Rest leg alongside the body
Rest leg alongside the body
Grasp foot along both sides
Grasp foot along both sides
Gently pull toward ear until resistance felt
Gently pull toward ear until resistance felt
Scores based on location of heel to landmarks
Scores based on location of heel to landmarks
Measurement unreliable if frank breech in utero
Measurement unreliable if frank breech in utero
4
4
3
3
2
2
1
1
0

0
-
-
1
1
ear
ear
nose
nose
chin
chin
nipple line
nipple line
umbilical area
umbilical area
femoral crease
femoral crease
© K. Karlsen 2006
Heel-to-Ear
Heel-to-Ear
4
4
3
3
2
2
1
1
0
0

-
-
1
1
ear
ear
nose
nose
chin
chin
nipple line
nipple line
umbilical area
umbilical area
femoral crease
femoral crease
2
1
0
© K. Karlsen 2006
Heel-to-Ear
Heel-to-Ear
4
4
3
3
2
2
1
1

0
0
-
-
1
1
4
ear
ear
nose
nose
chin
chin
nipple line
nipple line
umbilical area
umbilical area
femoral crease
femoral crease
3
© K. Karlsen 2006
Neuromuscular Maturity
Neuromuscular Maturity
Heel to ear
Heel to ear
Scarf sign
Scarf sign
Popliteal
Popliteal
angle

angle
Arm recoil
Arm recoil
Square
Square
window
window
(wrist)
(wrist)
Posture
Posture
Physical Maturity
Physical Maturity
Female
Female
Genitals
Genitals
Male
Male
Genitals
Genitals
Eyes / ears
Eyes / ears
Breast
Breast
Plantar
Plantar
surface
surface
Lanugo

Lanugo
Skin
Skin
Thick cartilage
Ear stiff
Formed and
firm
Instant recoil
Well-curved
pinna
Soft but ready
recoil
Slightly
curved pinna
Soft slow recoil
Lids open
Pinna flat
Stays folded
Lids fused:
Loosely: -1
Tightly: -2
Testes
pendulous
Deep rugae
Testes down
Good rugae
Testes
descending
Few rugae
Testes in upper

canal
Rare rugae
Scrotum empty
Faint rugae
Scrotum flat,
smooth
Majora cover
clitoris and
minora
Majora large
Minora small
Majora and
minora equally
prominent
Prominent
clitoris
Enlarging
minora
Prominent
clitoris
Small labia
minora
Clitoris
prominent
Labia flat
Full areola
5-10 mm bud
Raised areola
3-4 mm bud
Stippled areola

1-2 mm bud
Flat areola no
bud
Barely
perceptible
Im-perceptible
Creases over
entire sole
Creases
anterior 2/3
Anterior
transverse
crease only
Faint red marks
> 50 mm
No crease
Heel- toe
40-50 mm
< 40 = -2
Mostly baldBald Areas
Thinning
Lanugo
Abundant
lanugo
Sparse lanugoNo lanugo
Parchment
Deep cracking
No vessels
4
4

Cracking
Pale areas
Rare veins
3
3
Leathery
Cracked
Wrinkled
5
5
Superficial
peeling and/or
rash
Few veins
Smooth pink
Visible veins
Gelatinous
Red
Translucent
Sticky
Friable
Transparent
2
2
1
1
0
0
-
-

1
1
Gestational
Age
Evaluation
Gestational
Age
Evaluation
10 + 15 = 25
10 + 15 = 25
15
15
15
10
10
10
Sum scores
Sum scores
© K. Karlsen 2006
Sum scores
Sum scores
Neuromuscular
Neuromuscular
Physical maturity
Physical maturity
Total score correlates to
Total score correlates to
weeks gestation
weeks gestation
20

20
-
-
10
10
22
22
-
-
5
5
24
24
0
0
44
44
50
50
42
42
45
45
40
40
40
40
38
38
35

35
36
36
30
30
34
34
25
25
32
32
20
20
30
30
15
15
28
28
10
10
26
26
5
5
Wks
Wks
Score
Score
10 + 15 = 25

10 + 15 = 25
Gestational
Age
Evaluation
Gestational
Age
Evaluation
A detailed monograph and explanation about
how to perform the Ballard exam
(written by Dr. Ballard), may be found at
www.BallardScore.com