Continuing Education Activity

The Apgar score is a standardized assessment of a neonate's status immediately after birth, and the response to resuscitation efforts, and remains the gold standard for evaluating neonates. Although the Apgar score was initially designed to assess the need for intervention to establish breathing at 1 minute, the Neonatal Resuscitation Program guidelines state that Apgar scores should not be used to determine the initial need for intervention, what interventions are indicated, or when to initiate them, as resuscitation must be commenced before the 1-minute Apgar score is assigned. The Apgar score should not be interpreted in isolation but as part of a complete assessment, with resuscitation always taking precedence over scoring. 

This course delves into the clinical significance and intricacies of Apgar scoring, which involves evaluating 5 vital signs of newborns: color, heart rate, reflexes, muscle tone, and respiration. A score of 7 to 10 at 1 and 5 minutes is considered reassuring, but factors such as gestational age, birth weight, maternal medications, and congenital anomalies can influence scores. This activity for healthcare professionals is designed to enhance the learner's competence in using the Apgar score, evaluating the criteria to assign the score, and implementing an appropriate interprofessional approach when administering this assessment to improve ongoing monitoring and care beyond the initial scoring period for evaluating and managing newborns.

Objectives:

• Identify the physiological criteria used for calculating the Apgar score.
• Interpret the clinical relevance of the Apgar score.
• Determine the limitations of the Apgar score.
• Apply interprofessional team strategies to improve care coordination and patient outcomes when evaluating newborns using the Apgar score.

Introduction

The Apgar score is a rapid method for assessing a neonate immediately after birth and following resuscitation. Apgar scoring remains the accepted assessment method endorsed by the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP). While originally designed in 1952 by Dr. Virginia Apgar, an anesthesiologist at Columbia University, to assess the need for intervention to establish breathing at 1 minute, the guidelines for the Neonatal Resuscitation Program state that Apgar scores should not be used to determine the initial need for intervention, what interventions are indicated, or when to initiate them, as resuscitation must be commenced 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, including cyanosis, hypoperfusion, bradycardia, hypotonia, respiratory depression, or apnea. Each element is scored 0, 1, or 2. The score is recorded at 1 and 5 minutes after delivery in all infants, with expanded recording at 5-minute intervals for infants who score 7 or less at 5 minutes and for 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 because it provides somewhat subjective information about an infant's physiology at a point in time. Resuscitation should always take precedence over calculating a clinical score. 

Indications

Apgar scoring is indicated in all newborn infants at 1 and 5 minutes and should be documented in the clinical record. For infants scoring less than 7, ACOG and AAP encourage expanded Apgar score recording as a method of monitoring the response to resuscitation.[4][5][6]

Contraindications

Apgar scoring has no known contraindications in the evaluation of newborns. However, in certain situations (eg, an infant who needs to be paralyzed or undergo surgery at birth), the score may not reflect the underlying physiology.

Equipment

While most auscultation is performed with a stethoscope rather than by palpation, the most accurate method remains an electrocardiogram.[7] No other equipment is required. A pulse oximeter may also be used. Ideally, a radiant warmer and an electrocardiogram should be readily available in the delivery suite to provide the necessary warmth for neonates with hypothermia and to provide a more accurate heart rate if resuscitation is required. Alternatively, warm blankets and a stethoscope could be used.

Personnel

Any trained healthcare professional may calculate the Apgar score depending on the situation, including:

• Neonatologist
• Pediatrician
• Nurse practitioner
• Family physician
• Midwife
• Nurse
• Respiratory Therapist

Technique or Treatment

The Apgar score comprises 5 components. Each category is weighted evenly and assigned a 0, 1, or 2 value. The components are then added to give a score recorded 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 low in full-term and late preterm infants at 5 minutes. When an infant has a score of less than 7, the Neonatal Resuscitation Program guidelines recommend continued recording at 5-minute intervals up to 20 minutes. Scoring during resuscitation is not equivalent to an infant not undergoing resuscitation because resuscitative efforts alter several score elements.[8][9]

The score is calculated using the following assessment:

• Breathing effort

  • If the neonate is not breathing, the respiratory score is 0.
  • If respirations are slow and irregular, weak, or gasping, the respiratory score is 1.
  • If the neonate is crying vigorously, the respiratory score is 2.

• Heart rate

  • The heart rate is evaluated with a stethoscope or an electrocardiogram and 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 <100 bpm, the heart rate score is 1.
  • If the heart rate is >100 bpm, the heart rate score is 2.

• Muscle tone

  • In inactive neonates with loose, floppy muscle tone, the muscle tone score is 0.
  • In neonates demonstrating some tone and flexion, the score for muscle tone is 1.
  • In neonates in active motion with a flexed muscle tone that resists extension, the muscle tone score is 2.

• Grimace response or reflex irritability in response to stimulation

  • In a neonate with no reaction to stimulation, the reflex irritability response score is 0.
  • A neonate grimacing in response to stimulation has a reflex irritability response score of 1.
  • In a neonate who cries, coughs, or sneezes on stimulation, the reflex irritability response is 2.

• Color

  • Most infants will score 1 for color even at the 5-minute mark, as peripheral cyanosis is common among normal infants. Color can also be misleading in non-white infants.[10]
  • If the neonate is pale or blue, the color score is 0.
  • If the infant is pink, but the extremities are blue, the score for color is 1.
  • If the neonate is entirely pink, the color score is 2.

Clinical Significance

Apgar scores were designed to help identify infants who 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. While some evidence suggests poor long-term outcomes in infants with a low Apgar score at 1 minute, changes in scores from 1 to 5 minutes and individual scores at 5 and 10 minutes are more predictive.[11][12][11][13][14][15]

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.[16] 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. There is an inverse relationship between Apgar scores at 5 and 10 minutes and an increased relative risk of cerebral palsy and neonatal morbidity, including for even slightly lower Apgar scores.[17][16][17] Apgar scores that remain at 0 after 10 minutes are predictive of a poor outcome, though a significant portion of those babies survive, and many have no neurodevelopmental disabilities.[16][18] Experts no longer recommend terminating resuscitative efforts at 10 minutes with an Apgar score of 0.[18]

Enhancing Healthcare Team Outcomes

The Apgar score is a rapid, standardized method for assessing a newborn’s physiologic status immediately after birth and following resuscitation. Endorsed by ACOG and AAP, it evaluates heart rate, respiratory effort, muscle tone, reflex irritability, and color at 1 and 5 minutes after delivery, with continued 5-minute scoring for infants with scores below 7 or those requiring resuscitation. Although useful for monitoring neonatal transition and response to interventions, the Apgar score is subjective, influenced by gestational age, medications, and congenital anomalies, and should never delay or replace resuscitative care. The Apgar score is not a diagnostic tool for asphyxia or long-term neurologic outcomes.

Physicians, advanced practitioners, midwives, respiratory therapists, and nurses play pivotal roles in Apgar scoring, with consistency in scoring crucial to mitigate inter-rater variability. Interprofessional team members each assess neonates and promptly communicate any changes in Apgar scores to the attending clinician. Health professionals each play a crucial role in documenting scores at 1 and 5 minutes and collaborating with other clinicians on initial resuscitative measures for low-scoring neonates. Interprofessional communication ensures findings are shared with the mother and family, facilitating collaborative care planning. Physicians, advanced practitioners, midwives, and nurses should address family concerns, provide education leaflets, and emphasize patient education for managing neonates with low Apgar scores. This collaborative approach fosters optimal patient-centered care, enhancing outcomes and safety through effective team performance.

Nursing, Allied Health, and Interprofessional Team Interventions

Nurses caring for newborns should know the Apgar score and its significance. They should understand that a score between 7 and 10 is average; a score between 4 and 6 needs immediate reevaluation. A score at or below 3 is a sign of an emergency, and the nurse should immediately call a code and inform the clinician.

Nursing, Allied Health, and Interprofessional Team Monitoring

Components that the interprofessional team should monitor in newborns include:

• Apgar scoring at 1 and 5 minutes
• The general condition of the neonate
• Vital signs of the newborn
• Umbilical cord pH
• Arterial blood gases of the newborn

Review Questions

• Access free multiple choice questions on this topic.
• Click here for a simplified version.
• 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.

Phillipos E, Solevåg AL, Pichler G, Aziz K, van Os S, O'Reilly M, Cheung PY, Schmölzer GM. Heart Rate Assessment Immediately after Birth. Neonatology. 2016;109(2):130-8. [PubMed: 26684743]

8.

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]

9.

Gillam-Krakauer M, Shah M, Gowen Jr CW. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Oct 5, 2024. Birth Asphyxia. [PubMed: 28613533]

10.

Edwards SE, Wheatley C, Sutherland M, Class QA. Associations between provider-assigned Apgar score and neonatal race. Am J Obstet Gynecol. 2023 Feb;228(2):229.e1-229.e9. [PubMed: 35932875]

11.

Razaz N, Cnattingius S, Persson M, Tedroff K, Lisonkova S, Joseph KS. One-minute and five-minute Apgar scores and child developmental health at 5 years of age: a population-based cohort study in British Columbia, Canada. BMJ Open. 2019 May 09;9(5):e027655. [PMC free article: PMC6528022] [PubMed: 31072859]

12.

AMERICAN ACADEMY OF PEDIATRICS COMMITTEE ON FETUS AND NEWBORN; AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS COMMITTEE ON OBSTETRIC PRACTICE. The Apgar Score. Pediatrics. 2015 Oct;136(4):819-22. [PubMed: 26416932]

13.

Selvaratnam RJ, Wallace EM, Davis PG, Rolnik DL, Fahey M, Davey MA. The 5-minute Apgar score and childhood school outcomes. Acta Paediatr. 2022 Oct;111(10):1878-1884. [PubMed: 35665536]

14.

Chen HY, Chauhan SP. Apgar score at 10 minutes and adverse outcomes among low-risk pregnancies. J Matern Fetal Neonatal Med. 2022 Dec;35(25):7109-7118. [PubMed: 34167421]

15.

Chen HY, Blackwell SC, Chauhan SP. Association between apgar score at 5 minutes and adverse outcomes among Low-Risk pregnancies. J Matern Fetal Neonatal Med. 2022 Apr;35(7):1344-1351. [PubMed: 32299290]

16.

Persson M, Razaz N, Tedroff K, Joseph KS, Cnattingius S. Five and 10 minute Apgar scores and risks of cerebral palsy and epilepsy: population based cohort study in Sweden. BMJ. 2018 Feb 07;360:k207. [PMC free article: PMC5802319] [PubMed: 29437691]

17.

Razaz N, Cnattingius S, Joseph KS. Association between Apgar scores of 7 to 9 and neonatal mortality and morbidity: population based cohort study of term infants in Sweden. BMJ. 2019 May 07;365:l1656. [PMC free article: PMC6503461] [PubMed: 31064770]

18.

Shukla VV, Bann CM, Ramani M, Ambalavanan N, Peralta-Carcelen M, Hintz SR, Higgins RD, Natarajan G, Laptook AR, Shankaran S, Carlo WA. Predictive Ability of 10-Minute Apgar Scores for Mortality and Neurodevelopmental Disability. Pediatrics. 2022 Apr 01;149(4) [PubMed: 35296895]

Disclosure: Leslie Simon declares no relevant financial relationships with ineligible companies.

Disclosure: Manan Shah declares no relevant financial relationships with ineligible companies.

Disclosure: Bradley Bragg declares no relevant financial relationships with ineligible companies.