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APGAR Score
Simon LV, Hashmi MF, Bragg BN.

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 APGAR score in fostering the best possible standard of care to newborns and
their families.

Earn continuing education credits (CME/CE) on this topic.

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. 

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]

Contraindications
There are no known contraindications to APGAR scoring in the evaluation of newborns.

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,

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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.

Personnel
Neonatologist
Nurse practitioner
Family physician
Midwife

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.

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 outcome 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 risk of the poor neurologic outcome. 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

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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 outcome 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.

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 to 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]

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.

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

Continuing Education / Review Questions

Access free multiple choice questions on this topic.
Earn continuing education credits (CME/CE) on this topic.
Comment on this article.

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: PMC6204407] [PubMed: 30405441]
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: PMC6181089] [PubMed: 30323688]
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: PMC8039809] [PubMed: 30208498]
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: PMC6607701] [PubMed: 31320908]
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: 31723237]
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: 31198125]
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: 29436276]

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8. Gillam-Krakauer M, Gowen Jr CW. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 30, 2020. Birth Asphyxia.
[PubMed: 28613533]
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: PMC5796735] [PubMed: 29035696]

Publication Details

Author Information

Authors

Leslie V. Simon1; Muhammad F. Hashmi2; Bradley N. Bragg3.

Affiliations
1 Mayo Clinic Florida
2 National Health Service
3 Mayo Clinic Florida

Publication History

Last Update: February 11, 2021.

Copyright
Copyright © 2021, StatPearls Publishing LLC.

This book is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use,
duplication, adaptation, distribution, and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, a link is
provided to the Creative Commons license, and any changes made are indicated.

Publisher

StatPearls Publishing, Treasure Island (FL)

NLM Citation

Simon LV, Hashmi MF, Bragg BN. APGAR Score. [Updated 2021 Feb 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.

https://www.ncbi.nlm.nih.gov/books/NBK470569/ 4/4