Calculating Due Dates

and the
Impact of Mistaken Estimates of Gestational
Age
Janelle Durham, for Certification with Birth Education NW. January,
2002.

Introduction. This paper will examine the methods used by

obstetricians to predict the date on which a baby will be born, and also
examine how that forecasted due date affects the course of obstetric
treatment. Calculating a due date is a very challenging task as many
factors go into the equation. First, there’s the question of when the
pregnancy began: some women know the date of ovulation or
conception, but typically, due dates are based upon the woman’s last
menstrual period, a method which carries much potential for error.
Second, there’s a question of how long the pregnancy will last. As I
discuss in this paper, there’s a great deal of variability in “normal”
gestational terms for human babies, so predicting a due date typically
has a margin of error of a few weeks on each side of the date.
Psychological and Emotional Effects of Due Dates . The predicted due
date has an impact on the psychology of pregnant women and their
partners. Although their physician or childbirth educator may have told
them that the “due date” is only an estimate, many modern American
women take it as a scheduled date around which to make their plans.
Some parts of popular culture, like baby betting pools, remind us that
the date is difficult to guess; however, other messages imply that we
can expect a certain date. The Girlfriend’s Guide to Pregnancy even
has a countdown calendar to the due date… there is a token message
there saying something like “baby’s not here yet? Well, take care of
yourself and be patient.” But clearly the message is to expect the baby
then, despite the fact that only 4-5% of babies are born on their exact
due date.
In this paper, I will not address this emotional and psychological impact
in much detail, but this data should be read with an awareness of this,
because it certainly impacts the couples that we work with in childbirth
preparation classes. For example, as childbirth educators, we
frequently see women who have reached the 38th week of pregnancy,
where they’re told the baby is ‘no longer premature’ and the moms are
ready for the baby to come. By the time they are past 40 weeks, they
are ready for induction, despite knowledge of the risks and side effects
of induction.
Medical Decision-Making Based on Due Dates. There are several cases
in which medical management of a pregnancy is based on a knowledge
of the specific gestational age of the fetus. These include:
interpretation of pre-natal test results, determination of the best date
for a planned cesarean section, decisions about inducing a ‘post-date’
pregnancy. Errors in estimates of fetal age can lead to further errors,
including iatrogenic prematurity, and unnecessary inductions. Despite
protocols that have been developed to reduce these errors, some
persist, as even physicians can be overly literal in their beliefs about
the baby’s due date.
Public Health Record-Keeping. Records of gestational age at birth are
used to help determine rates of pre-term births, and to help evaluate
the effectiveness of prenatal care. Inaccurate estimates of fetal age
could make this information harder to interpret.
How accurate are due dates in the experience of the average American
mom?
With the current formula, about 2/3 of babies are born within ten days
of their due dates, with approximately 80% of babies born sometime
between week 38 and 42 after LMP.
Because visual representation of data is often helpful for illustrating a
point, I have included a graph here illustrating the range of dates at
which babies are born. The following graph is intended as an
illustration of approximately how many births occur within each week
of pregnancy. The data on here is not exact, as it is a composite from
multiple sources. I have found multiple references that state that about
6% of babies are pre-term, and that 4-14% of babies would be born
after 42 weeks (Odutayo, and others), if it were not for interventions,
so the far ends of the scale relate to this data. Galimberti states that
3.5% of labors start spontaneously at 37 weeks, 9.5% at 38 weeks, and
18.5% at week 39. Klimek has an evenly distributed Gauss curve, or
bell curve, but does not substantiate it with empirical data. Therefore,
my data for weeks 40 and 41 are only estimates, based on a bell curve
format.

What is the “normal gestational term” for humans?

Naegele’s Rule: The standard definition for gestational term is 266
days from conception to the date of the baby’s birth. This is also
defined as 280 days, or 40 weeks, from the first day of the mother’s
last menstrual period, a definition which assumes that the mother
ovulates on day 14 of a 28 day menstrual cycle. The formula used to
calculate due date is:
(LMP + 7 days) – 3 months = Due Date
This definition is based on observations, first reported by Franz
Naegele in 1812, who believed that pregnancy lasted ten lunar months
from the last menstrual period. It was not based on empirical data.
Mittendorf’s Observations of Gestational Term. In the 1980’s,
Mittendorf noticed that birth dates for women in his practice, primarily
second-generation Irish-Americans, averaged seven days past their
“due dates”. He reviewed his records, then went on to review records
of 17,000 births, and determined the average healthy, white, private-
care, primiparous woman averaged 288 days from LMP to birth: 8 days
longer than Naegele’s rule. Mittendorf and other researchers have
further determined several factors that affect gestational term,
including ethnicity, parity, nutrition, substance use, mother’s age, and
mother’s size. Based on Mittendorf’s data, a more appropriate formula
might be:
(LMP – 3 months) + 15* Days = Due Date
* Add 10, rather than 15, if mother is non-white, or multiparous

Normal Variations in Gestational Term:

From the wide range in birth dates, it is clear that some variation is
normal. Some examples of known variations: Multiparous women
average 283 days, versus the 288 days of multiparous women.
(Mittendorf) Black women averaged 8.5 days fewer than white women
of similar socioeconomic status. (Mittendorf) Other studies indicate
that for multiple births, each additional baby in the uterus shortens the
pregnancy by 4 weeks on average.
When is a baby physically mature? By standard definitions, 38-42
weeks LMP is normal, before 37 weeks is considered premature and
after 42 weeks is considered a post-date pregnancy. Klimek argues
that this interpretation may not always be correct. He states if there is
this wide of range, then clearly it is normal for some babies to take 38
or fewer weeks to develop to full-term development, when others may
take more than 42 weeks to reach maturity. He compares this to the
range at which human beings reach puberty, and points out that no
one sets a “required” age for puberty, or takes medical steps to induce
puberty in ‘late-bloomers.’
Certainly in practice, there are examples which would support this
theory. After the baby is born, it is possible to develop Clinical
Estimates of Fetal Age. There are various methods for assessing a
baby’s stage of physical development (see appendix for two sample
scales). The baby is also weighed and measured, and those numbers
are compared to average growth charts. Medical staff assess babies,
and classify them as AGA (appropriate for gestational age) if they’re in
the 10th to 90th percentile, or LGA (large for gestational age), or SGA
(Small for gestational age) if they are in the outlying ranges. Nurses
are taught that babies who are AGA have a better chance for survival
than those who are large or small for gestational age, so this helps to
establish a general risk factor for the baby. However, by anecdotal
evidence, it is clear that some babies born at 37-38 weeks are fully
mature by all the criteria on the scale, and other babies born at 42
weeks are just reaching the signs of being mature, “term” infants.
Alaska’s Bureau of Vital Statistics examined data on preterm babies,
and compared two measures of gestational age to determine how
accurate the reports were: the LMP method and Clinical Estimation of
Gestational Age after the birth. “The LMP gestational calculation has a
wider distribution (by two weeks) for the 5th and 95th percentiles and
a larger standard deviation. Higher levels of very preterm, preterm,
and postterm births was shown by the LMP based gestation. A clear
preference for a gestational age of 40 weeks was shown by the CE
measure. More than 1/3 (35.1%) of births had a CE gestational age of
40 weeks. This compares with 23.2% for the LMP-based measure.
Overall, the CE measure classified almost 9 of every 10 births as a
term birth.” The difference between the supposed “actual” age of the
baby (LMP) and the observed maturity level of the baby could be
accounted for partially by errors in determining LMP, but it is also
possible that it is due in part to the Klimek’s idea of a normal variation
in how long a fetus takes to reach maturity. It is possible that some of
the babies who were “premature” by LMP standards tested fine on CE
measures simply because of a faster rate of fetal development. Some
of the “post-term” babies by LMP standards may have tested as term
babies because of a naturally slower rate of development.

Table 1
Another interesting finding in this study is that “Native infants with an
LMP-based gestation of 32 weeks or less showed an average CE
gestational age that was from 1 to 3 weeks higher than the
comparable group of non-Native infants. The data do suggest that
Native infants on average weigh slightly more than non-Native infants,
which could partially explain the difference, especially if birth weight
was used to help estimate gestation. It could also be that the reported
date of last menses is more problematic for Native births.” I would
suggest that is might also reflect a shorter average gestational term
for Native babies. Although this study did not examine that possibility,
a similar variation was seen for African-American babies in Mittendorf’s
work, and racial differences may well appear elsewhere.

Summary of gestational term issues. It appears that average length of

pregnancy varies significantly from mother to mother, dependent on a
variety of factors, not all of which have been studied and explored.
This makes due date calculation difficult, even if the exact date of
conception were known. However, as we see below, due date
prediction is further compounded by uncertainty about when the
pregnancy began.
When did pregnancy begin (i.e. when do we start counting gestational
age)?
Based on date of conception and/or ovulation. Some women are aware
of when they ovulate, either based on formal methods and record-
keeping such as daily temperature checks, or on physical symptoms
such as mild pain upon ovulation, or observation of changes in vaginal
mucus. Many women know the dates when conception was possible,
because they know the dates when they had intercourse during their
most recent menstrual cycle. Due dates can be calculated based on
these dates, but many physicians prefer to calculate it from date of
last menstrual period. They may only calculate from conception date if
conception was medically managed and supervised through
techniques such as artificial insemination.
Based on date of last normal menstrual period. Due dates are typically
calculated based upon the date the last menstrual period began,
according to the mother’s report. Naegele’s rule assumes that
ovulation occurred 14 days after LMP, which is only the case for
women with 28 day cycles. Some caregivers will ask their patients for a
history of menstrual cycles so that they can adjust this number, as
appropriate, for cycles of different lengths or irregular cycles. It’s also
important to consider: recent use of oral contraceptives, and their
possible effect on ovulation date; inaccurate memory about when the
last period occurred, the possibility of interpreting post-conception
‘spotting’ as a light period, and unrecognized pregnancy losses. These
issues all complicate due date prediction, and it’s estimated that
nearly 25% of infants who would be classified as preterm birth on the
basis of the last normal menstrual period are not preterm. (cited in
Health Canada)
Ultrasound: Developing an Estimate of Fetal Age Based on Baby’s Size
Ultrasound can be used to estimate age, by comparing measurements
against average fetal growth curves. Crown-Rump Length is measured
in the first trimester. Later, they measure the length of the femur,
abdominal circumference, head circumference, and diameter across
the head (bi-parietal diameter).
Odutayo states that ultrasound is a better method of determining fetal
age than LMP. His findings indicate that birth occurred on the due date
in 3.6% of cases with LMP dating, and 4.3% of cases where due date
was determined by ultrasound. Delivery took place within seven days
of the due date for 49.5% of LMP due dates, and for 55.2% of
ultrasound due dates. Delivery within ten days of the due date was
64.1% for LMP dates, and 70.3% for ultrasound dates.
Due to these findings, and others: If ultrasound measurements
correspond closely to LMP dating, then they are viewed as a
confirmation of the LMP date. If ultrasound measurements suggest a
significantly different date from the LMP date, many physicians will use
the ultrasound date for planning treatment and intervention, rather
than using the LMP date. Protocols vary, but generally say that if the
dates very by more than one week, or by ten days according to some
protocols, especially if LMP is uncertain for any reason, then the
ultrasound date is used.
However, because of the significant margin of error in ultrasound
measurements, Otto and Platt (1991) argue that the due date should
not be changed unless the discrepancy is more than two weeks.
In the first trimester, the margin of error for determining baby’s
gestational age is +/- 3-5 days. Therefore, early ultrasounds can often
be fairly good indicators of fetal age. However, past the first trimester,
babies grow at very different rates, so size is much less accurate for
determining fetal age. Up to 20 weeks, the margin of error is +/- 7-10
days. At 20- 30 weeks: +/- 2 weeks. After 32 weeks, fetal age
estimates may be up to 3 weeks off in either direction. Therefore, a
baby that appears “term” (40 weeks) may be anywhere from 37-43
weeks gestational age.
Other Methods for cross-checking gestational age:
Additional sources of information about baby’s age can be found.
Physical estimation of baby’s size can be done by clinical exam and
fundal measurement, and then compared to growth charts, similar to
the ultrasound method. Quickening: Pregnant women usually first feel
fetus move by 16-20 weeks; some believe the baby will arrive 5
months after quickening. Fetal heart tones can indicate gestational
age. They can be heard through Doppler starting at 9-12 weeks and by
stethoscope at 18-20 weeks. However, a simple summary of our ability
to predict due dates is that all clinical dating methods have margins of
error of more than two weeks.
Problems with inaccurate due dates / gestational age estimates:
Prenatal Testing. Inaccurate dates can affect the accuracy of prenatal
testing where the interpretation of test results requires a knowledge of
the specific gestational age of the baby. For example, if the caregiver
has not heard the baby’s heart beat by a certain gestational age, then
there may be cause for concern. However, if he is looking for it ‘too
early’ because of an error in calculating gestational age, then he may
cause un-needed fear and anxiety for the parents.
Another example: the triple screen test (AFP test) is done between 16
and 18 weeks LMP. It measures the levels of protein produced by the
fetus, and two pregnancy-produced hormones in the mother’s blood.
These levels are compared to where the baby’s levels “should” be at
this point in pregnancy, and if discrepancies appear, then further
testing, such as amniocentesis may be done to determine the baby’s
risk of Down syndrome or other abnormalities. If the fetal age has been
misdiagnosed, then the levels will not be appropriately evaluated, and
there is a chance that the mother will have an unnecessary
amniocentesis, which carries a potential risk to the fetus. (example
from Summons, et al)
Iatrogenic Prematurity. In cases of elective cesarean section or
medically-indicated induction, a serious risk is iatrogenic prematurity:
a baby that is premature because the interventions were performed
too early due to error in determining gestational age. This could be
prematurity in the more typical sense: if the estimated date of
conception (based on LMP) is significantly wrong, then the baby would
be delivered prior to 38 weeks of age. It could also be any infant who
had not reached full maturity, regardless of weeks of development.
“Thus a preterm birth can occur even at the 42nd week just as a
postterm birth is possible even at the 38th week.” (Klimek)
Incidence: It has been estimated that 10% of the time the gestational
age based on LMP is significantly inaccurate. In some studies, as many
as 10% of admissions to neonatal intensive care are due to inadvertent
iatrogenic prematurity. (Clewell) Shreiner et al. examined a sample of
47 infants that developed respiratory distress syndrome following
elective abdominal delivery “at term.” The mean difference between
the gestational age determined pre-natally (by methods such as LMP
or ultrasound) and post-natally (by clinical exam) was 2.6 weeks, +/-
1.6 weeks.
Ways to reduce risk: some hospitals and groups (e.g. ACOG, College of
Physicians and Surgeons of Manitoba) have established protocols to
determine fetal maturity before elective cesarean. These require clear
documentation of gestational age based on multiple indicators such as:
clear menstrual history, prenatal exam records, Doppler record of fetal
heart tone for 30 weeks, more than 36 weeks since a positive urine
pregnancy test, and ultrasound estimates of gestational age performed
before 20 weeks. If these data are not available, then they recommend
amniocentesis: amniotic fluid analysis of the lecithin-to-sphingomyelin
(L/S) ratio and phosphatidylglycerol to provide evidence of fetal lung
maturity.
Allowing the woman to go into spontaneous labor before c-section
would also markedly reduce the risk: The risks of iatrogenic
prematurity and lung disease for those infants delivered by elective
cesarean before labor are 30 percent versus those born by cesarean
after labor begins (11 percent). (PCRM)

Inductions performed for “overdue” babies that are not actually

overdue.
“Between 4% and 14% (average 10%) of women are prepared to reach
42 weeks gestation, and 2% to 7% (average 4%) to reach 43 weeks
gestation depending on the population studied.” (Odutayo) In the
overwhelming majority of these pregnancies, the fetus remains
healthy, as does the mother.
However, with pregnancies that have passed their 41 week line,
physicians become concerned about the baby developing postmaturity
syndrome. Some potential concerns: The placenta, which supplies
babies with the nutrients and oxygen from the mother’s circulation,
begins to age toward the end of pregnancy, and may not function as
efficiently as before. Amniotic fluid volume may decrease and the fetus
may stop gaining weight or may even lose weight. Problems may
occur during birth if the baby is large. Postmature babies may be at
risk for meconium aspiration, when a baby breathes in fluid containing
the first stool. Hypoglycemia (low blood sugar) can also occur because
the baby has too few glucose-producing stores.
Due to concerns about postmaturity, many physicians have a standard
policy of inducing labor at a certain gestational age. Labor is induced in
more than 13% of deliveries in the U.S., and post-date pregnancy is
the most common reason for induction. This is despite the fact, as
Nichols (1985) states: studies of management have not found that
tests accurately identify postmature babies or that routine induction
improves perinatal outcome. And, according to ACOG, 95% of babies
born between 42 and 44 weeks are born safely. Only a small
percentage of pregnancies that last beyond 42 weeks result in babies
with post-maturity syndrome. These numbers may reflect issues
addressed above: the period for normal prenatal development for a
human infant appears to span several weeks. Some so-called late
babies may merely have been slow to develop, and are born at the
term that is appropriate to their development.
So, there is some question whether it is appropriate to induce labor at
42 weeks of gestation, and this issue is further complicated by all the
concerns about inaccurate dating of conception, as described above.
Nichols (1985b) states that 70% of women classified as postdate in his
study were incorrectly dated. If the choice to induce is based on
menstrual dating, this is likely to result in a high proportion of
unnecessary inductions. “In studies where conception has been
estimated from basal body temperature charts, and ultrasound
measurements, it has been shown that the error in menstrual dating is
heavily skewed to the right - i.e., there is a tendency to overestimate
gestation.” (Odutayo)
Ultrasonography in the first half of pregnancy could reduce the number
of pregnancies classified as >42 weeks from 11.5 to 3.5 (i.e., by 70%).
(Odutayo)
However, even with multiple methods for dating the pregnancy, there
is still a margin for error in determining the age of the baby, and
further questions regarding the age at which this particular baby will
reach obstetrical maturity.
Therefore, some research based protocols for post-date pregnancy
recommend that with late date pregnancy, tests may be started to
evaluate the mother and fetus for signs of postmaturity. Tests include
fetal movement counting, ultrasound examination, non-stress test,
contraction stress test, and estimation of the amount of amniotic fluid.
If these indicate potential postmaturity, the doctor can perform
amniocentesis to check for meconium staining of the amniotic fluid
before pursuing labor induction. If the fetal well-being tests do not
detect signs of postmaturity, a post-date pregnancy may be allowed to
continue until labor begins spontaneously.
Teaching Gestational Age and Due date information to students:
Within the context of a childbirth preparation class, there simply isn’t
time to cover most of this information. However, some can be
included. I believe that providing parents with some of the information
about the normal range of gestational term could help them to develop
reasonable expectations regarding how likely it is that their child will
arrive on its due date, and allow them to prepare themselves to follow
advice of: “be ready for the baby after 38 weeks, but don’t be
surprised if it doesn’t come till 42 weeks.” Hopefully the knowledge of
the normal variation, and of the general well-being of “late babies”
may help to alleviate some of the anxiety about post-date pregnancy
and help women to not be overly eager to induce labor upon reaching
40 weeks.
How I cover this information in a class series. In the first class, when
discussing Onset of Labor, I address due dates, and the question of
“When will my Baby Arrive?” I explain briefly how due dates are
calculated, and have them calculate their due date if their pregnancy
lasted Mittendorf’s 288 average days rather than Naegele’s 280 days. I
then point out that if they reach a point where their doctor-determined
due date has passed, and they are frustrated and ready for the baby to
come, they should remember Mittendorf’s rule, and try not to get
impatient yet.
Once this concept has been introduced, students have some
knowledge of the normal range of pregnancy length and the problems
with estimating fetal age. I can then refer back to this as reminder and
reinforcement of the concept in later classes, when talking about:
induction risks and alternatives, post-date pregnancies, and the
emotional frustrations of late pregnancy when parents, especially
mothers, are ready for pregnancy to end, and parenting to begin.
Bibliography:

Alaska Bureau of Vital Statistics. “A Comparison of Gestational Age

Information Derived from the Birth Certificate, 1990-1998.”
Clewell, William H. “Fetal Lung Maturity Testing.” Arizona Society of
Pathologists' Newsletter.
Children’s Hospital of Pittsburgh website. Postmaturity: The High Risk
Newborn.
The College of Physicians and Surgeons of Manitoba, revised 1995.
“Prevention Of Iatrogenic Prematurity”
Devoe, LD; Sholl, JS. “Postdates pregnancy. Assessment of fetal risk
and obstetric management.” Journal of Reproductive Medicine,
28(9): 576-80. 1983.
Galimberti, A. “Neonatal respiratory morbidity following delivery by
elective caesarean section at term: an audit and a review.”
Harman, Jefferson H. and Andrew Kim. “Current Trends in Cervical
Ripening and Labor Induction” American Family Physician, August,
1999.
Health Protection Branch, Health Canada. “Pre-term Birth” in
“Measuring Up: A Health Surveillance Update on Canadian Children
and Youth.”
Isidro-Cloudas, Terry. “Pregnancy past your due date” on
americanbaby.com
Klimek, Rudy, “The use in obstetrics of quantum theory as well as
modern technology to decrease the morbidity and mortality of
newborns and mothers during iatrogenic induced delivery”
Neuroendocrinology Letters, 2001.
Klimek M. “Prediction of the birth term and course of the labor.”
Archives of Perinatal Medicine, 7(3):24-29, 2001
Merck. “The Merck Manual Home Edition.”
Mittendorf, et al. “The Length of Uncomplicated Human Gestation”
Obstetrics & Gynecology, V.75, N.6, June 1990 pp. 929-932.
Parilla, BV; Dooley, SL; Jansen, RD; Socol, ML. “Iatrogenic respiratory
distress syndrome following elective repeat cesarean delivery.”
Obstetrics and Gynecology, 81(3): 392-5. 1993.
Physician’s Committee for Responsible Medicine, “When is Surgery
Unnecessary?”
Schreiner, RL; Stevens, DC; Smith, WL; Lemons, JA, Golichowski, AM;
Padilla, LM. “Respiratory Distress following elective repeat cesarean
section.” American Journal of Obstetrics and Gynecology, 143(6):
689-92. 1982.
Simkin, Penny. “How Long is too long?” Childbirth Forum, Spring 1993.
Summons, Peter, Warwick Giles and Greg Gibbon. “Decision Support
for Fetal Gestation Age Estimation” from the Proceedings of the 10th
Australasian conference on Information Systems, 1999.
Wagner, Marsden. “Being Seduced to Induce: What women should
know about their OBs.” Excerpted from Midwifery Today E-News,
notes from a lecture in New York City, April 2001.
“When will my baby be born?” found at
http://pregnancy.about.com/library/weekly/aa042197.htm
Dubowitz/Ballard Exam for Gestational Age
Neuromuscular Maturity

Posture: With the infant supine and quiet, score as follows:

• Arms and legs extended = 0
• Slight or moderate flexion of hips and knees = 1
• Moderate to strong flexion of hips and knees = 2
• Legs flexed and abducted, arms slightly flexed = 3
• Full flexion of arms and legs = 4
Square Window: Flex the hand at the wrist. Exert pressure sufficient to get as much
flexion as possible. The angle between the hypothenar eminence and the anterior
aspect of the forearm is measured and scored: >90 degrees = –1; 90º = 0; 60º = 1;
45º = 2; 30º = 3; 0º = 4
Arm Recoil: With the infant supine, fully flex the forearm for 5 seconds, then fully
extend by pulling the hands and release. Score the reaction:
• Remains extended 180 degrees, or random movements = 0
• Minimal flexion, 140-180 degrees = 1
• Small amount of flexion, 110-140 degrees = 2
• Moderate flexion, 90-100 degrees = 3
• Brisk return to full flexion, <90 degrees = 4
Popliteal Angle: With the infant supine and the pelvis flat on the examining surface,
the leg is flexed on the thigh and the thigh fully flexed with the use of one hand. With
the other hand the leg is then extended and the angled scored: 180º = -1; 160º = 0;
140º = 1; 120º = 2; 100º = 3; 90º = 4; <90º = 5
Scarf Sign: With the infant supine, take the infant's hand and draw it across the neck
and as far across the opposite shoulder as possible. Assistance to the elbow is
permissible by lifting it across the body. Score according to the location of the elbow:
• Elbow reaches or nears level of opposite shoulder = -1
• Elbow crosses opposite anterior axillary line = 0
• Elbow reaches opposite anterior axillary line = 1
• Elbow at midline = 2
• Elbow does not reach midline = 3
• Elbow does not cross proximate axillary line = 4
Heel to Ear: With the infant supine, hold the infant's foot with one hand and move it
as near to the head as possible without forcing it. Keep the pelvis flat on the
examining surface. Score as shown in the diagram above.

Physical Maturity
Sign -1 0 1 2 3 4 5
Skin Sticky, friable, Gelatinous Smooth Superficial Cracking, Parchment, Leathery,
transparent red, pink, visible peeling pale deep cracked,
translucent veins and/or rash, areas, rare cracking, no wrinkled
few veins veins vessels
Lanugo None Sparse Abundant Thinning Bald areas Mostly bald
Plantar Heel-toe 40- Heel-toe Faint red Anterior Creases Creases
Creases 50 mm = -1, >50 mm, no marks transverse over over entire
<40 mm = -2 creases crease only anterior sole
2/3
Breast Imperceptible Barely Flat areola, Stippled Raised Full areola,
perceptible no bud areola, 1-2 areola, 3-4 5-10 mm
mm bud mm bud bud
Eye & Lids fused, Lids open, Slightly Well-curved Formed Thick
Ear loosely = -1, pinna flat, curved pinna, soft and firm, cartilage,
tightly = -2 stays folded pinna, soft but ready with ear stiff
with slow recoil instant
recoil recoil
Genitals, Scrotum flat, Scrotum Testes in Testes Testes Testes
male smooth empty, faint upper descending, down, pendulous,
rugae canal, rare few rugae good deep rugae
rugae rugae
Genitals, Clitoris Prominent Prominent Majora and Majora Majora
female prominent, clitoris, clitoris, minora large, cover
labia flat small labia enlarging equally minora clitoris and
minora minora prominent small minora

Maturity Rating
Add up the individual Neuromuscular and Physical Maturity scores for
the twelve categories, then obtain the estimated gestational age from
the table below.

Total Score Gestational Age, Weeks Total Score Gestational Age, Weeks
-10 20 25 34
-5 22 30 36
0 24 35 38
5 26 40 40
10 28 45 42
15 30 50 44
20 32

References
"New Ballard Score, expanded to include extremely premature
infants," by Ballard, JL, et al, Journal of Pediatrics, September 1991,
page 417.
"A simplified score for assessment of fetal maturation of newly born
infants," Journal of Pediatrics 95:769, 1979.
Klaus and Fanaroff, "Care of the High-Risk Neonate," Third Edition,
pages 80-83.

Scoring System for Clinical Assessment of Klimek’s

maturation index in newborn infants.

 Back