Apgar score

       
Apgar is a quick test performed on a baby at 1 and 5 minutes after birth. The 1-minute score
determines how well the baby tolerated the birthing process. The 5-minute score tells the health care
provider how well the baby is doing outside the mother's womb.

In rare cases, the test will be done 10 minutes after birth.

Virginia Apgar, MD (1909-1974) introduced the Apgar score in 1952.

How the Test is Performed

The Apgar test is done by a doctor, midwife, or nurse. The provider examines the baby's:

 Breathing effort

 Heart rate

 Muscle tone

 Reflexes

 Skin color

Each category is scored with 0, 1, or 2, depending on the observed condition.

Breathing effort:

 If the infant is not breathing, the respiratory score is 0.

 If the respirations are slow or irregular, the infant scores 1 for respiratory effort.

 If the infant cries well, the respiratory score is 2.

Heart rate is evaluated by stethoscope. This is the most important assessment:

 If there is no heartbeat, the infant scores 0 for heart rate.

 If heart rate is less than 100 beats per minute, the infant scores 1 for heart rate.

 If heart rate is greater than 100 beats per minute, the infant scores 2 for heart rate.

Muscle tone:

 If muscles are loose and floppy, the infant scores 0 for muscle tone.
 If there is some muscle tone, the infant scores 1.

 If there is active motion, the infant scores 2 for muscle tone.

Grimace response or reflex irritability is a term describing response to stimulation, such as a mild
pinch:

 If there is no reaction, the infant scores 0 for reflex irritability.

 If there is grimacing, the infant scores 1 for reflex irritability.

 If there is grimacing and a cough, sneeze, or vigorous cry, the infant scores 2 for reflex irritability.

Skin color:

 If the skin color is pale blue, the infant scores 0 for color.

 If the body is pink and the extremities are blue, the infant scores 1 for color.

 If the entire body is pink, the infant scores 2 for color.

Why the Test is Performed

This test is done to determine whether a newborn needs help breathing or is having heart trouble.

Normal Results
The Apgar score is based on a total score of 1 to 10. The higher the score, the better the baby is
doing after birth.

A score of 7, 8, or 9 is normal and is a sign that the newborn is in good health. A score of 10 is very
unusual, since almost all newborns lose 1 point for blue hands and feet, which is normal for after
birth.

What Abnormal Results Mean

Any score lower than 7 is a sign that the baby needs medical attention. The lower the score, the
more help the baby needs to adjust outside the mother's womb.

Most of the time a low Apgar score is caused by:

 Difficult birth

 C-section

 Fluid in the baby's airway

A baby with a low Apgar score may need:

 Oxygen and clearing out the airway to help with breathing

 Physical stimulation to get the heart beating at a healthy rate

Most of the time, a low score at 1 minute is near-normal by 5 minutes.

A lower Apgar score does not mean a child will have serious or long-term health problems. The
Apgar score is not designed to predict the future health of the child.

Alternative Names
Newborn scoring; Delivery - Apgar

Images

 Infant care following delivery

 Newborn test


References
Arulkumaran S. Fetal surveillance in labor. In: Arulkumaran SS, Robson MS, eds. Munro Kerr's
Operative Obstetrics. 13th ed. Philadelphia, PA: Elsevier; 2020:chap 9.
Goyal NK. The newborn infant. In: Kliegman RM, St. Geme JW, Blum NJ, Shah SS, Tasker RC,
Wilson KM, eds. Nelson Textbook of Pediatrics. 21st ed. Philadelphia, PA: Elsevier; 2020:chap 113.
Review Date 10/2/2020
Updated by: Neil K. Kaneshiro, MD, MHA, Clinical Professor of Pediatrics, University of Washington
School of Medicine, Seattle, WA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda
Conaway, Editorial Director, and the A.D.A.M. Editorial team.

At 1 minute, only 11% of babies had an Apgar score of 10, but this proportion increased to 89%
at 5 minutes and 97% at 10 minutes. At all three time points, including 1 minute, an Apgar
score of 10 was strongly associated with lower mortality and morbidity than a score of 7, 8, or 9.
 Apgar Score: What You Should
Know
 Apgar rubric

 Normal Apgar score

 Conclusions

What is the Apgar score?

The Apgar score is a scoring system doctors and nurses use to assess
newborns one minute and five minutes after they’re born.

Dr. Virginia Apgar created the system in 1952, and used her name as a
mnemonic for each of the five categories that a person will score. Since that
time, medical professionals across the world have used the scoring system to
assess newborns in their first moments of life.

Medical professionals use this assessment to quickly relay the status of a

newborn’s overall condition. Low Apgar scores may indicate the baby needs
special care, such as extra help with their breathing.

Usually after birth, a nurse or doctor may announce the Apgar scores to the
labor room. This lets all present medical personnel know how a baby is doing,
even if some of the medical personnel are tending to the mom.

When a parent hears these numbers, they should know they’re one of many
different assessments medical providers will use. Other examples include
heart rate monitoring and umbilical artery blood gases. However, assigning an
Apgar score is a quick way to help others understand the baby’s condition
immediately after birth.

How does the Apgar score work?

The Apgar scoring system is divided into five categories. Each category
receives a score of 0 to 2 points. At most, a child will receive an overall score
of 10. However, a baby rarely scores a 10 in the first few moments of life. This
is because most babies have blue hands or feet immediately after birth.

A: Activity/muscle tone

 0 points: limp or floppy

 1 point: limbs flexed
 2 points: active movement

P: Pulse/heart rate

 0 points: absent
 1 point: less than 100 beats per minute
 2 points: greater than 100 beats per minute

G: Grimace (response to stimulation, such as suctioning the baby’s nose)

 0 points: absent
 1 point: facial movement/grimace with stimulation
 2 points: cough or sneeze, cry and withdrawal of foot with stimulation

A: Appearance (color)
  0 points: blue, bluish-gray, or pale all over
 1 point: body pink but extremities blue
 2 points: pink all over

R: Respiration/breathing

 0 points: absent
 1 point: irregular, weak crying
 2 points: good, strong cry

The Apgar scores are recorded at one and five minutes. This is because if a
baby’s scores are low at one minute, a medical staff will likely intervene, or
increased interventions already started.

At five minutes, the baby has ideally improved. If the score is very low after
five minutes, the medical staff may reassess the score after 10 minutes.
Doctors expect that some babies may have lower Apgar scores. These
include:

 premature babies
 babies born via cesarean delivery
 babies who had complicated deliveries

What’s considered a normal

Apgar score?
A score of 7 to 10 after five minutes is “reassuring.” A score of 4 to 6 is
“moderately abnormal.”
A score of 0 to 3 is concerning. It indicates a need for increased intervention,
usually in assistance for breathing. A parent may see nurses drying off a child
vigorously or delivering oxygen via a mask. Sometimes a doctor, midwife, or
nurse practitioner may recommend transferring a patient to a neonatal
intensive care nursery for further assistance.

Many doctors don’t considerTrusted Source the Apgar scoring system to be

perfect. There are modifications to this scoring system, such as the
Combined-Apgar score. This scoring system describes not only the baby’s
Apgar score, but also the interventions an infant has received.

The maximum score of the Combined-Apgar score is 17, which indicates a

baby who hasn’t received any interventions and receives all points. A score of
0 indicates the baby didn’t respond to interventions.

Conclusions on Apgar score

While the Apgar score has value in helping medical providers understand how
a baby is doing immediately after birth, the score doesn’t usually have any
bearing on how healthy a baby is long term.

Also, because a person is assigning the number, the Apgar score is

subjective. One person could score a baby a “7” while another could score the
baby a “6.” This is why the Apgar score is just one of several assessments
used to evaluate a newborn’s general condition.

Apgar Scores
As soon as your baby is born, a delivery nurse will set one timer for one minute and another for
five minutes. When each of these time periods is up, a nurse or physician will give your baby her
first "tests," called Apgars.

This scoring system (named after its creator, Virginia Apgar) helps the physician estimate your
baby's general condition at birth.

What Does the Apgar Test Measure?

The test measures your baby's:

 Heart rate
 Breathing
 Muscle tone
 Reflex response
 Color
It cannot predict how healthy she will be as she grows up or how she will develop; nor does it
indicate how bright she is or what her personality is like. But it does alert the hospital staff if she
is sleepier or slower to respond than normal and may need assistance as she adapts to her new
world outside the womb.

How is the Apgar Test Scored?

Each characteristic is given an individual score; two points for each of the five categories if all is
completely well; then all scores are totaled. For example, let's say your baby has a heart rate of
more than 100, cries lustily, moves actively, grimaces and coughs in response to the syringe, but
is blue; her one minute Apgar score would be 8—two points off because she is blue and not
pink. Most newborn infants have Apgar scores greater than 7. Because their hands and feet
remain blue until they are quite warm, few score a perfect 10.

 If your baby's Apgar scores are between 5 and 7 at one minute, she may have
experienced some problems during birth that lowered the oxygen in her blood. In this
case, the hospital nursing staff probably will dry her vigorously with a towel while
 oxygen is held under her nose. This should start her breathing deeply and improve her
oxygen supply so that her five-minute Apgar scores total between 8 and 10.
 A small percentage of newborns have Apgar scores of less than 5. For example,
babies born prematurely or delivered by emergency C-section are more likely to have low
scores than infants with normal births. These scores may reflect difficulties the baby
experienced during labor or problems with her heart or respiratory system.
What if Your Baby Scores Low?
If your baby's Apgar scores are very low, a mask may be placed over her face to pump oxygen
directly into her lungs. If she's not breathing on her own within a few minutes, a tube can be
placed into her windpipe, and fluids and medications may be administered through one of the
blood vessels in her umbilical cord to strengthen her heartbeat. If her Apgar scores are still low
after these treatments, she will be taken to the special-care nursery for more intensive medical
attention.

Apgar Scoring System

Last Updated
 
9/25/2015
Source
 
Caring for Your Baby and Young Child: Birth to Age 5, 6th Edition (Copyright © 2015 American
Academy of Pediatrics)
The information contained on this Web site should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations
in treatment that your pediatrician may recommend based on individual facts and circumstances.
APGAR Score
Leslie V. Simon; Muhammad F. Hashmi; Bradley N. Bragg.

Author Information

Last Update: August 14, 2021.

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Continuing Education Activity

In 1952, Dr. Virginia Apgar, an anesthesiologist at Columbia University, developed the Apgar
score. Serendipitously, APGAR is also a useful mnemonic to describe the components of the
score: appearance, pulse, grimace, activity, and respiration. The score is a rapid method for
evaluating neonates immediately after birth and in response to resuscitation. Apgar scoring
remains the accepted method of assessment and is endorsed by both the American College of
Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP).
While originally designed to assess the need for intervention to establish breathing at 1 minute,
the guidelines for the Neonatal Resuscitation Program (NRP) state that Apgar scores do not
determine the initial need for intervention as resuscitation must be initiated before the 1-minute
Apgar score is assigned. This activity reviews the Apgar score and its clinical relevance and
highlights the role of the interprofessional team in the evaluation and management of newborns.
Objectives:
 Identify the physiological criteria used for calculating the Apgar score.
 Describe the clinical relevance of the Apgar score.
 Outline the limitations of the Apgar score.
 Explain the importance of coordinated collaboration and effective communication among
the interprofessional team members involved in the evaluation and management of
newborns using the APGAR score in fostering the best possible standard of care to
newborns and their families.
Access free multiple choice questions on this topic.
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Introduction
In 1952, Dr. Virginia Apgar, an anesthesiologist at Columbia University, developed the Apgar
score. The score is a rapid method for assessing a neonate immediately after birth and in
response to resuscitation.  Apgar scoring remains the accepted method of assessment and is
endorsed by both the American College of Obstetricians and Gynecologists and the American
Academy of Pediatrics. While originally designed to assess the need for intervention to establish
breathing at 1 minute, the guidelines for the Neonatal Resuscitation Program9NRP) state that
Apgar scores do not determine the initial need for intervention as resuscitation must be initiated
before the 1-minute Apgar score is assigned.[1][2][3]
Elements of the Apgar score include color, heart rate, reflexes, muscle tone, and respiration.
Apgar scoring is designed to assess for signs of hemodynamic compromise such as cyanosis,
hypoperfusion, bradycardia, hypotonia, respiratory depression, or apnea. Each element is
scored 0 (zero), 1, or 2. The score is recorded at 1 minute and 5 minutes in all infants with
expanded recording at 5-minute intervals for infants who score seven or less at 5 minutes, and in
those requiring resuscitation as a method for monitoring response. Scores of 7 to 10 are
considered reassuring.
Apgar scores may vary with gestational age, birth weight, maternal medications, drug use or
anesthesia, and congenital anomalies. Several components of the score are also subjective and
prone to inter-rater variability. Thus, the Apgar score is limited in that it provides somewhat
subjective information about an infant’s physiology at a point in time. It is useful in gauging the
response to resuscitation but should not be used to extrapolate outcomes, particularly at 1 minute
as this does not hold any long-term clinical significance. Apgar score alone should not be
interpreted as evidence of asphyxia and its significance in outcome studies while widely reported
is often inappropriate. Resuscitation should always take precedence over calculating a clinical
score. 
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Indications
Apgar scoring is recorded in all newborn infants at 1 minute and 5 minutes. In infants scoring
less than 7, expanded Apgar score recording is encouraged by the American College of
Obstetrics and Gynecology and the American Academy of Pediatrics as a method of monitoring
response to resuscitation.[4][5][6]
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Contraindications
There are no known contraindications to APGAR scoring in the evaluation of newborns.
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Equipment
Auscultation with a stethoscope rather than by palpitation of a pulse best assesses heart rate. No
other equipment is required. Auscultation is a more accurate way to count the pulse as compared
to palpation of an umbilical or brachial pulse. A pulse oximeter may also be used. Ideally, a
radiant warmer should be readily available in the delivery suite, to provide the necessary warmth
for neonates with hypothermia. Alternatively, warm blankets could be used.
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Personnel
 Neonatologist
 Nurse practitioner
  Family physician
 Midwife
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Technique
There are five parts of an Apgar score. Each category is weighted evenly and assigned a value of
0, 1, or 2. The components are then added together to give a total score that is recorded at 1 and 5
minutes after birth. A score of 7 to 10 is considered reassuring, a score of 4 to 6 is moderately
abnormal, and a score of 0 to 3 is deemed to be low in full-term and late preterm infants. At 5
minutes, when an infant has a score of less than 7, Neonatal Resuscitation Program guidelines
recommend continued recording at 5-minute intervals up to 20 minutes. It should be noted that
scoring during resuscitation is not equivalent to that of an infant not undergoing resuscitation
because resuscitative efforts alter several elements of the score.[7][8]
The score is calculated as follows:
Breathing Effort
 If the infant is not breathing, the respiratory score is 0.
 If respirations are slow and irregular, weak or gasping, the respiratory score is 1.
 If the infant is crying vigorously, the respiratory score is 2.
Heart Rate
 Note, heart rate is evaluated with a stethoscope, and it is the most critical part of the score
in determining the need for resuscitation.
 If there is no heartbeat, the heart rate score is 0.
 If the heart rate is less than 100 beats per minute, the heart rate score is 1.
 If the heart rate is more than 100 beats per minute, the heart rate score is 2.
Muscle Tone
 If the muscle tone is loose and floppy without activity, the score for muscle tone is 0.
 If the infant demonstrates some tone and flexion, the score for muscle tone is 1.
 If the infant is in active motion with a flexed muscle tone that resists extension, the score
for muscle tone is 2.
Grimace Response or Reflex Irritability in Response to Stimulation
 If there is no response to stimulation, the reflex irritability response score is 0.
 If there is grimacing in response to stimulation, the reflex irritability response score is 1.
 If the infant cries, coughs, or sneezes on stimulation, the reflex irritability response is 2.
Color
 Note, most infants will score 1 for color as peripheral cyanosis is common among normal
infants. Color can also be misleading in non-white infants.
 If the infant is pale or blue, the score for color is 0.
 If the infant is pink, but the extremities are blue, the score for color is 1.
 If the infant is entirely pink, the score for color is 2.
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Clinical Significance
Apgar scores were designed to help identify infants that require respiratory support or other
resuscitative measures, not as an outcome measure. The Apgar score alone should not be
considered evidence of asphyxia or proof of an intrapartum hypoxic event. A low Apgar score of
0 to 1 at 1 minute is not predictive of adverse clinical outcomes or long-term health issues since
most infants, even those with very low 1-minute scores will have normal scores by 5 minutes.
Low Apgar scores at 5 minutes correlate with mortality and may confer an increased risk of
cerebral palsy in population studies but not necessarily with an individual neurologic disability.
Most infants with low Apgar scores do not go on to develop cerebral palsy, but lower scores over
time increase the population's risk of poor neurologic outcomes. Scores less than five at 5 and 10
minutes correlate with an increased relative risk of cerebral palsy. Neonates with scores less than
five at 5 minutes should have umbilical artery blood gas sampling performed. Apgar scores that
remain at 0 after 10 minutes may indicate that the termination of resuscitative efforts is
appropriate as very few infants survive with good neurologic outcomes if no heart rate has been
detectable for over 10 minutes.[9]
The Apgar score alone should not be considered as evidence of asphyxia or evidence of an
intrapartum hypoxic event. A low Apgar score of 0 to 1 at 1 minute is not predictive of adverse
clinical outcomes or long-term health issues since most infants, even those with very low 1-
minute scores will have normal scores by 5 minutes. Low Apgar scores at 5 minutes correlate
with mortality and may confer an increased risk of cerebral palsy in population studies but not
necessarily with an individual neurologic disability.
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Enhancing Healthcare Team Outcomes

Apgar scoring may be performed by a physician, midwife, or nurse. Inter-rater variability is
quite common as some components of the score are subjective, so ideally, the same person
should calculate the initial and ongoing scores for consistency. The nurse has a crucial role in
evaluating neonates using the APGAR score, and she should inform the clinician of any
untoward changes in the APGAR score of the newborn. The nurse should document the findings
of the APGAR score at 1 minute and 5 minutes, respectively. The nurse assists the clinician in
the initial resuscitative measures of the neonates, particularly if they have low APGAR scores.
The interprofessional team should communicate the findings of the resuscitation efforts to the
woman and her family and should formulate a care plan for neonates with low APGAR scores.
The nurse should collaborate with the clinician to address any concerns, the woman and her
family might have. The nurse should provide the woman with the necessary information leaflets
about neonatal care. Patient education is key to the successful management of neonates with low
APGAR scores. The best possible standard of care could only be achieved through coordinated
collaboration and clear communication among the members of the interprofessional team.  [level
V]
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Nursing, Allied Health, and Interprofessional Team Interventions

Nurses looking after newborns should be familiar with the Apgar score. Also, they should know
what the score signifies. Nurses should understand that a score between 7-10 is normal; a score
between 4-6 needs proper reevaluation as the infant does require monitoring for 5 minutes. A
score of less than 3 is never good, and immediate attention is mandatory. The nurse should call a
code and inform the clinician immediately.
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Nursing, Allied Health, and Interprofessional Team Monitoring

 APGAR scoring at 1 and 5 minutes
 General condition of the neonate
 Vital signs of the newborn
 Umbilical cord pH
 Arterial blood gases of the newborn
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Review Questions
 Access free multiple choice questions on this topic.
 Comment on this article.
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References
1.
Medeiros TKS, Dobre M, da Silva DMB, Brateanu A, Baltatu OC, Campos LA.
Intrapartum Fetal Heart Rate: A Possible Predictor of Neonatal Acidemia and APGAR
Score. Front Physiol. 2018;9:1489. [PMC free article] [PubMed]
2.
 Yeagle KP, O'Brien JM, Curtin WM, Ural SH. Are gestational and type II diabetes
mellitus associated with the Apgar scores of full-term neonates? Int J Womens
Health. 2018;10:603-607. [PMC free article] [PubMed]
3.
Ayrapetyan M, Talekar K, Schwabenbauer K, Carola D, Solarin K, McElwee D, Adeniyi-
Jones S, Greenspan J, Aghai ZH. Apgar Scores at 10 Minutes and Outcomes in Term and
Late Preterm Neonates with Hypoxic-Ischemic Encephalopathy in the Cooling Era. Am J
Perinatol. 2019 Apr;36(5):545-554. [PMC free article] [PubMed]
4.
Vuralli D. Clinical Approach to Hypocalcemia in Newborn Period and Infancy: Who
Should Be Treated? Int J Pediatr. 2019;2019:4318075. [PMC free article] [PubMed]
5.
Goswami IR, Whyte H, Wintermark P, Mohammad K, Shivananda S, Louis D, Yoon
EW, Shah PS., Canadian Neonatal Network Investigators. Characteristics and short-term
outcomes of neonates with mild hypoxic-ischemic encephalopathy treated with
hypothermia. J Perinatol. 2020 Feb;40(2):275-283. [PubMed]
6.
Odintsova VV, Dolan CV, van Beijsterveldt CEM, de Zeeuw EL, van Dongen J,
Boomsma DI. Pre- and Perinatal Characteristics Associated with Apgar Scores in a
Review and in a New Study of Dutch Twins. Twin Res Hum Genet. 2019 Jun;22(3):164-
176. [PubMed]
7.
Day KE, Prince AC, Lin CP, Greene BJ, Carroll WR. Utility of the Modified Surgical
Apgar Score in a Head and Neck Cancer Population. Otolaryngol Head Neck Surg. 2018
Jul;159(1):68-75. [PubMed]
8.
Gillam-Krakauer M, Gowen Jr CW. StatPearls [Internet]. StatPearls Publishing; Treasure
Island (FL): Aug 30, 2020. Birth Asphyxia. [PubMed]
9.
Nair A, Bharuka A, Rayani BK. The Reliability of Surgical Apgar Score in Predicting
Immediate and Late Postoperative Morbidity and Mortality: A Narrative
Review. Rambam Maimonides Med J. 2018 Jan 29;9(1) [PMC free article] [PubMed]

What does your baby’s Apgar score mean?

November 24, 2015

Robyn Horsager-Boehrer, M.D.Obstetrics and Gynecology

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Don’t get too wrapped up in your baby’s Apgar score; it almost never reflects a baby’s
future health.
Babies take their first test one minute after birth. Apgar scores have been assigned
to newborns for more than half a century, although they are often misunderstood by
parents.

The test was developed by anesthesiologist Virginia Apgar, who wanted a way to
compare the effects of different practices on newborn babies. For example, if there
were two different pain medications that a mother could receive, she wanted to be
able to measure and compare the effects on the newborns immediately after birth.

How the test is administered and scored remains unchanged since 1952, although
today we typically see it as a tool to assess how a baby is transitioning from fetal life
to newborn life.

I find that parents tend to obsess over their baby’s Apgar score. In this day and age
where competition starts early in life, a low score looks like their baby didn’t perform
well. Parents can recall their children’s Apgar scores like they do their own
SAT scores – I know I do. But we also need to remember that the Apgar score is
not generally a predictor of future health, it’s just a quick glimpse at a newborn’s
condition at a specific point in time.

What does the Apgar test measure?

The Apgar test scores five elements on a scale of 0 to 2 for a total score that can
range from 0 to 10:
The test is given to a baby both at one minute and five minutes after birth. If the Apgar
score is below 7 at five minutes, we’ll do it again at 10 minutes.
This doesn’t mean that if your baby needs help breathing, we sit around and wait
until the one-minute test tells us so. We’ll start resuscitation efforts immediately if
it’s needed. The Apgar score is just a quick way for us to assess a newborn’s
condition at one minute of life.

If your baby doesn’t get a 10 at one minute or even after five minutes, don’t worry.
Very few babies get a perfect Apgar score – in fact at our hospital, fewer than 1 in
100 get that perfect 10. Most newborns lose at least a point for color; it’s normal for
a baby’s hands and feet to be a little blue – it’s just part of the process a baby’s
circulation goes through adapting to life outside the uterus. If your baby’s score is
7 or more, you should be reassured that your baby is transitioning well.

What does an Apgar score mean for a baby’s future?

If your baby gets low Apgar scores at one and five minutes, very rarely does it
mean your baby will have a difficult newborn course or face a life of health
problems. There are a lot of things than can impact a baby’s score.
For example, my second daughter had scores of 2 and 7 at one minute and five
minutes of life. Two may sound scary and way too low to be normal, but she was the
second of a twin delivery, she was breech, and she was premature. All these things
can impact the scores. Sedation also can affect an Apgar score. If mom has
received pain medication recently, the baby may be a little sleepy from the drug and
have less respiratory effort.

If the Apgar score is below 7 at five or 10 minutes, we may need additional

information from the delivery – don’t panic, it doesn’t mean that something bad
happened during your delivery. Was the baby undergoing a procedure at the time
the score was taken? What does the blood test from the umbilical artery tell us?
Does an examination of the placenta help explain the infant’s condition? Taking a
look at the bigger picture can often give us more clues to how the infant is
transitioning to newborn life and what might have made the transition a little
more rocky than normal.

Putting the Apgar score into perspective

The American Academy of Pediatrics (AAP) and the American College of Obstetricians
and Gynecologists (ACOG) released a joint policy statement in September in an effort
to remind healthcare providers and the public to keep Apgar scores in perspective.
“The Apgar score alone cannot be considered to be evidence of or a
consequence of asphyxia, does not predict individual neonatal mortality or
neurologic outcome, and should not be used for that purpose.” That’s a strong
statement that I think should be reassuring to parents.

Also in the statement, the groups encourage healthcare professionals to take

additional information into account when interpreting the Apgar score. In the event
the infant needs additional attention In the delivery room, they even suggest a
modified record that provides more details on exactly what was happening with the
infant in the first few minutes of life – things like medications given and whether the
infant was requiring additional oxygen. The goal is to have the most accurate
picture of what the infant’s condition is early in life.

The Apgar Score

 Committee Opinion CO

 Number 644
 October 2015

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Number 644 (Replaces Committee Opinion Number 333, May 2006. Reaffirmed 2021)
Committee on Obstetric Practice
American Academy of Pediatrics—Committee on Fetus and Newborn
This document reflects emerging clinical and scientific advances as of the date issued
and is subject to change. The information should not be construed as dictating an
exclusive course of treatment or procedure to be followed. This document reflects
emerging concepts on patient safety and is subject to change. The information should
not be construed as dictating an exclusive course of treatment or procedure to be
followed.

ABSTRACT: The Apgar score provides an accepted and convenient method for

reporting the status of the newborn infant immediately after birth and the response to
resuscitation if needed. The Apgar score alone cannot be considered to be evidence of
or a consequence of asphyxia, does not predict individual neonatal mortality or
neurologic outcome, and should not be used for that purpose. An Apgar score assigned
during a resuscitation is not equivalent to a score assigned to a spontaneously
breathing infant. The American Academy of Pediatrics and the American College of
Obstetricians and Gynecologists encourage use of an expanded Apgar score reporting
form that accounts for concurrent resuscitative interventions.

Introduction
In 1952, Dr. Virginia Apgar devised a scoring system that was a rapid method of
assessing the clinical status of the newborn infant at 1 minute of age and the need for
prompt intervention to establish breathing 1. A second report evaluating a larger number
of patients was published in 1958 2. This scoring system provided a standardized
assessment for infants after delivery. The Apgar score comprises five components: 1)
color, 2) heart rate, 3) reflexes, 4) muscle tone, and 5) respiration, each of which is
given a score of 0, 1, or 2. Thus, the Apgar score quantitates clinical signs of neonatal
depression such as cyanosis or pallor, bradycardia, depressed reflex response to
stimulation, hypotonia, and apnea or gasping respirations. The score is reported at 1
minute and 5 minutes after birth for all infants, and at 5-minute intervals thereafter until
20 minutes for infants with a score less than 7 3. The Apgar score provides an accepted
and convenient method for reporting the status of the newborn infant immediately after
birth and the response to resuscitation if needed; however, it has been inappropriately
used to predict individual adverse neurologic outcome. The purpose of this statement is
to place the Apgar score in its proper perspective. This statement revises the 2006
College Committee Opinion and AAP Policy Statement to include updated guidance
from Neonatal Encephalopathy and Neurologic Outcome, Second Edition, along with
new guidance on neonatal resuscitation.
The Neonatal Resuscitation Program guidelines state that the Apgar score is

useful for conveying information about the newborn’s overall status and response to
resuscitation. However, resuscitation must be initiated before the 1-minute score is
assigned. Therefore, the Apgar score is not used to determine the need for initial
resuscitation, what resuscitation steps are necessary, or when to use them 3.
An Apgar score that remains 0 beyond 10 minutes of age may, however, be useful in
determining whether continued resuscitative efforts are indicated because very few
infants with an Apgar score of 0 at 10 minutes have been reported to survive with a
normal neurologic outcome 3 4 5. In line with this, the 2011 Neonatal Resuscitation
Program guidelines state that “if you can confirm that no heart rate has been detectable
for at least 10 minutes, discontinuation of resuscitative efforts may be appropriate” 3.
Neonatal Encephalopathy and Neurologic Outcome, Second Edition, published in 2014
by the College in collaboration with the AAP, defines a 5-minute Apgar score of 7–10 as
reassuring, a score of 4–6 as moderately abnormal, and a score of 0–3 as low in the
term infant and late-preterm infant 6. That document considers an Apgar score of 0–3 at
5 minutes or more as a nonspecific sign of illness, which “may be one of the first
indications of encephalopathy” 6. However, a persistently low Apgar score alone is not a
specific indicator for intrapartum compromise. Further, although the score is used widely
in outcome studies, its inappropriate use has led to an erroneous definition of
asphyxia. Asphyxia is defined as the marked impairment of gas exchange leading, if
prolonged, to progressive hypoxemia, hypercapnia, and significant metabolic acidosis.
The term asphyxia, which describes a process of varying severity and duration rather
than an end point, should not be applied to birth events unless specific evidence of
markedly impaired intrapartum or immediate postnatal gas exchange can be
documented based on laboratory testing 6.

Limitations of the Apgar Score

It is important to recognize the limitations of the Apgar score. The Apgar score is an
expression of the infant’s physiologic condition at one point in time, which includes
subjective components. There are numerous factors that can influence the Apgar score,
including maternal sedation or anesthesia, congenital malformations, gestational age,
trauma, and interobserver variability 6. In addition, the biochemical disturbance must be
significant before the score is affected. Elements of the score such as tone, color, and
reflex irritability can be subjective, and partially depend on the physiologic maturity of
the infant. The score also may be affected by variations in normal transition. For
example, lower initial oxygen saturations in the first few minutes need not prompt
immediate supplemental oxygen administration; the Neonatal Resuscitation Program
targets for oxygen saturation are 60–65% at 1 minute and 80–85% at 5 minutes 3. The
healthy preterm infant with no evidence of asphyxia may receive a low score only
because of immaturity 7 8. The incidence of low Apgar scores is inversely related to
birth weight, and a low score cannot predict morbidity or mortality for any individual
infant 8 9. As previously stated, it also is inappropriate to use an Apgar score alone to
diagnose asphyxia.

Apgar Score and Resuscitation

The 5-minute Apgar score, and particularly a change in the score between 1 minute and
5 minutes, is a useful index of the response to resuscitation. If the Apgar score is less
than 7 at 5 minutes, the Neonatal Resuscitation Program guidelines state that the
assessment should be repeated every 5 minutes for up to 20 minutes 3. However, an
Apgar score assigned during a resuscitation is not equivalent to a score assigned to a
spontaneously breathing infant 10. There is no accepted standard for reporting an
Apgar score in infants undergoing resuscitation after birth because many of the
elements contributing to the score are altered by resuscitation. The concept of an
assisted score that accounts for resuscitative interventions has been suggested, but the
predictive reliability has not been studied. In order to correctly describe such infants and
provide accurate documentation and data collection, an expanded Apgar score report
form is encouraged Figure 1. This expanded Apgar score also may prove to be useful
in the setting of delayed cord clamping, where the time of birth (complete delivery of the
infant), the time of cord clamping, and the time of initiation of resuscitation all can be
recorded in the comments box.
The Apgar score alone cannot be considered to be evidence of or a consequence of
asphyxia. Many other factors, including nonreassuring fetal heart rate monitoring
patterns and abnormalities in umbilical arterial blood gases, clinical cerebral function,
neuroimaging studies, neonatal electroencephalography, placental pathology,
hematologic studies, and multisystem organ dysfunction need to be considered in
diagnosing an intrapartum hypoxic–ischemic event 5. When a Category I (normal) or
Category II (indeterminate) fetal heart rate tracing is associated with Apgar scores of 7
or higher at 5 minutes, a normal umbilical cord arterial blood pH (± 1 standard
deviation), or both, it is not consistent with an acute hypoxic–ischemic event 6.

Prediction of Outcome
A 1-minute Apgar score of 0–3 does not predict any individual infant’s outcome. A 5-
minute Apgar score of 0–3 correlates with neonatal mortality in large populations 11 12,
but does not predict individual future neurologic dysfunction. Population studies have
uniformly reassured us that most infants with low Apgar scores will not develop cerebral
palsy. However, a low 5-minute Apgar score clearly confers an increased relative risk of
cerebral palsy, reported to be as high as 20-fold to 100-fold over that of infants with a 5-
minute Apgar score of 7–10 9 13 14 15. Although individual risk varies, the population
risk of poor neurologic outcomes also increases when the Apgar score is 3 or less at 10
minutes, 15 minutes, and 20 minutes 16. When a newborn has an Apgar score of 5 or
less at 5 minutes, umbilical artery blood gas from a clamped section of the umbilical
cord should be obtained, if possible 17. Submitting the placenta for pathologic
examination may be valuable.

Other Applications
Monitoring of low Apgar scores from a delivery service can be useful. Individual case
reviews can identify needs for focused educational programs and improvement in
systems of perinatal care. Analyzing trends allows for the assessment of the effect of
quality improvement interventions.
 Conclusions
The Apgar score describes the condition of the newborn infant immediately after birth
and, when properly applied, is a tool for standardized assessment 18. It also provides a
mechanism to record fetal-to-neonatal transition. Apgar scores do not predict individual
mortality or adverse neurologic outcome. However, based on population studies, Apgar
scores of less than 5 at 5 minutes and 10 minutes clearly confer an increased relative
risk of cerebral palsy, and the degree of abnormality correlates with the risk of cerebral
palsy. Most infants with low Apgar scores, however, will not develop cerebral palsy. The
Apgar score is affected by many factors, including gestational age, maternal
medications, resuscitation, and cardiorespiratory and neurologic conditions. If the Apgar
score at 5 minutes is 7 or greater, it is unlikely that peripartum hypoxia–ischemia
caused neonatal encephalopathy.

Recommendations
 The Apgar score does not predict individual neonatal mortality or neurologic
outcome, and should not be used for that purpose.

 It is inappropriate to use the Apgar score alone to establish the diagnosis of

asphyxia. The term asphyxia, which describes a process of varying severity and
duration rather than an end point, should not be applied to birth events unless specific
evidence of markedly impaired intrapartum or immediate postnatal gas exchange can
be can be documented.

 When a newborn has an Apgar score of 5 or less at 5 minutes, umbilical artery

blood gas from a clamped section of umbilical cord should be obtained. Submitting the
placenta for pathologic examination may be valuable.

 Perinatal health care professionals should be consistent in assigning an Apgar

score during resuscitation; therefore, the American Academy of Pediatrics (AAP) and
the American College of Obstetricians and Gynecologists (the College) encourage use
of an expanded Apgar score reporting form that accounts for concurrent resuscitative
interventions.
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Full text document also published in Pediatrics.

Copyright October 2015 by the American College of Obstetricians and Gynecologists,
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ISSN 1074-861X
The Apgar score. Committee Opinion No. 644. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2015;126:e52–5.