Newborn checked using Apgar Score

Everything about 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.

Why is Apgar Score necessary?

The one minute APGAR assessment provides information about the baby’s physical health and helps the physician determine if an immediate or future medical treatment will be required. The five-minute assessment measures how the baby has responded to previous resuscitation attempts if such attempts were made.

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 tone0 points: limp or floppy
1 point: limbs flexed
2 points: active movement


P: Pulse/heart rate0 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. Nurses 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 midwife, or nurse practitioner may recommend transferring a patient to a neonatal intensive care nursery for further assistance.

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Apgar Score and Resuscitation

The 5-minute Apgar score, particularly the change between 1 and 5 minutes, is a useful indicator of resuscitation responsiveness. The Neonatal Resuscitation Program recommendations specify that if the Apgar score is less than 7 after 5 minutes, the examination should be repeated every 5 minutes for up to 20 minutes. However, an Apgar score given during resuscitation is not the same as one given to a baby who is breathing normally. Because many of the variables that contribute to the score are affected by resuscitation, there is no established standard for reporting an Apgar score in newborns receiving resuscitation after birth.

Although the concept of an aided score that accounts for resuscitative treatments has been proposed, the predictive reliability of such a score has yet to be investigated. An enhanced Apgar score report form is recommended in order to accurately describe such infants and offer reliable documentation and data collecting. In the case of delayed cord clamping, the time of birth (full delivery of the infant), the time of cord clamping, and the time of resuscitation commencement can all be entered in the comments box.

The Apgar score cannot be considered evidence of or a result of asphyxia on its own. Other factors to consider in diagnosing an intrapartum hypoxic-ischemic event include unsettling heartbeat monitoring patterns and abnormalities in umbilical arterial blood gases, clinical cerebral function, neuroimaging studies, neonatal electroencephalography, placental pathology, hematologic investigations, and multisystem organ dysfunction. It is not consistent with an acute hypoxic-ischemic event when a Category I (normal) or Category II heartbeat tracing is linked with Apgar scores of 7 or higher at 5 minutes, a normal umbilical cord arterial blood pH, or both.

Stethoscope on the chest of a neonate, checking for R in Apgar
Stethoscope on the chest of a neonate

Clinical Significance of Apgar Score

Apgar scores were created to help in the identification of infants who needed breathing assistance or other resuscitative procedures, not as a measure of outcome. The Apgar score should not be used as confirmation of asphyxia or an intrapartum hypoxic episode on its own. Because most infants, even those with very low 1-minute Apgar scores, will have normal scores by 5 minutes, a low Apgar score of 0 to 1 at 1 minute is not predictive of a negative clinical result or long-term health difficulties. In population studies, low Apgar scores at 5 minutes are associated with death and may indicate an increased chance of cerebral palsy, but not necessarily with individual neurologic disability.

Although most infants with low Apgar scores do not acquire cerebral palsy, lower scores increase the population’s risk of poor neurologic outcomes over time. At 5 and 10 minutes, scores of less than five are associated with a higher relative risk of cerebral palsy. Umbilical artery blood gas collection should be performed on newborns with scores less than five at 5 minutes. If the Apgar score remains at 0 after 10 minutes, it may be time to stop resuscitative efforts because very few infants survive with good neurologic outcomes if there is no heart rate detectable for more than 10 minutes.

Limitations of the Apgar Score

It’s critical to understand the Apgar score’s limitations. The Apgar score is a subjective assessment of the infant’s physiologic status at a certain point in time. Maternal sedation or anaesthesia, congenital abnormalities, gestational age, trauma, and interobserver variability are all factors that can affect the Apgar score. Furthermore, before the score is changed, the metabolic disruption must be considerable. Tone, colour, and reflex irritability are subjective elements of the score that are influenced by the infant’s physiological maturity. Variations in normal transition may also have an impact on the score.

Lower initial oxygen saturations, for example, do not need the use of supplementary oxygen right away; the Neonatal Resuscitation Program’s oxygen saturation objectives are 60–65 percent at 1 minute and 80–85 percent at 5 minutes. Because of his or her immaturity, a healthy preterm child with no signs of hypoxia may obtain a low score. Low Apgar scores are inversely proportional to birth weight, and a low score cannot indicate morbidity or fatality in any given newborn. As previously indicated, using an Apgar score alone to diagnose hypoxia is ineffective.

Recommendations on Apgar score

Individual neonatal mortality or neurologic outcomes are not predicted by the Apgar score, and it should not be utilised for that purpose.

The Apgar score should not be used alone to determine the presence of asphyxia. Unless specific evidence of severely decreased intrapartum or immediate postnatal gas exchange can be recorded, the word asphyxia, which denotes a process of varying severity and length rather than an endpoint, should not be applied to birth events.

Umbilical artery blood gas from a clamped piece of the umbilical cord should be taken when a newborn has an Apgar score of 5 or less at 5 minutes. It may be beneficial to have the placenta pathologically examined.

During resuscitation, perinatal health care providers should assign an Apgar score consistently.

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.

Many factors influence the Apgar score, including maternal medications, resuscitation, and cardiorespiratory and neurologic problems. It is improbable that peripartum hypoxia-ischemia caused infant encephalopathy if the Apgar score at 5 minutes is 7 or higher.

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.

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