Apgar Score | What Is It?

Have you ever heard the term Apgar score and wondered what on earth it was?

Most parents are aware of it, but most don’t really understand what it means or what it measures.

When your baby is born and you’re soaking in those magical first moments, your health practitioner is quickly assessing baby’s overall wellbeing.

Your newborn undergoes her very first test within the first few moments of life.

This article gives the lowdown on what the Apgar score is, what it measures, and what it means for your baby.

Apgar score meaning

The Apgar score is named after American physician, obstetric anesthesiologist, and medical researcher Dr. Virginia Apgar (1909-1974).

Having begun her career intending to become a surgeon, Dr. Apgar switched career paths to anesthetics, after being disappointed at the lack of opportunities for women in the surgical field.

After many years of experience, and witnessing the affects of maternal anesthesia on newborns, Dr. Apgar began to realize that little attention was paid to infants and their physical condition after birth. Bear in mind, this was long before the use of fetal monitoring and machines.

In 1952, therefore, the Apgar test system was born.

What is the Apgar score?

Dr Virginia Apgar created a simple 5 point scoring method, now known as the Apgar test. It quickly assesses the physical condition of an infant in the first few minutes of life.

It was designed to focus attention on newborns’ specific needs, as patients in their own right, and on their vital signs, immediately after birth.

The scoring method aims to identify babies who need immediate neonatal resuscitation interventions, to help improve survival rates. The scores can also be used to assess an infant’s response to resuscitative measures.

This scoring system is now used globally, and has become the standardized way of assessing all newborn infants.

What does the Apgar score measure?

The APGAR acronym was developed as a learning aid, and describes the 5 points of the scoring system:

• A – Appearance (skin color)
• P – Pulse (heart rate)
• G – Grimace reflex (reflex irritability)
• A – Activity (muscle tone)
• R – Respiration (breathing effort).

Health care providers assign scores of either 0, 1, or 2 to each of the 5 categories, giving a total score out of 10.

Apgar scoring is performed at one minute following birth, with another assessment performed at 5 minutes after birth, for all babies.

For babies with a score of 7 or less at the 5-minute interval, the test is repeated every 5 minutes, up to 20 minutes, or until a score of 7 or greater is achieved.

Generally, the lower a baby’s Apgar score, the poorer the newborn’s physical condition.

Infants with lower Apgar scoring are likely to need some form of intervention or special care immediately after they are born. They might also need continued assessment, based on their condition.

How do you calculate the Apgar score?

Each category is scored from 0-2 depending on the newborn’s response, as follows:

Appearance

This is based on the color of the newborns’ skin. It isn’t related to their ethnic origin, but rather with the oxygen levels in the blood.

0 – is given if the body is pale or blueish in color. This is also known as cyanosis

1 – if the body is of a normal skin color but their hands and feet remain blueish

2 – is given if the baby’s body and extremities are pink.

Pulse

This refers to a newborn’s heart rate.

If there’s no heartbeat, or heart rate is very slow, oxygen levels are too low to support the major organs including the brain. This causes hypoxia (too little oxygen in the cells), leading to serious health problems, such as cerebral palsy.

0 – is scored if there is no heart rate

1 – is given if the newborn has a heart rate less than 100 BPM

2 – if the newborn has a heart rate greater than 100 BPM.

Grimace

The grimace reflex, or reflex irritability, refers to an infant’s response to stimulation – for example, a gentle pinch.

0 – is given if there’s no response to stimulation

1 – is scored if an infant shows some response to stimulation

2 – is given if there’s grimacing, or a reflex such as a vigorous cry, a cough, or a sneeze.

Activity

Activity refers to the infant’s muscle tone at birth.

If fetal distress has happened during labor, or if an infant isn’t able to breathe independently, oxygen levels will be low and the heart rate will fall.

This process causes a baby to be ‘floppy’ or have poor muscle tone (hypotonia).

0 – is given if a baby is floppy and unresponsive

1 – if there is some muscle tone in the trunk, limbs, or face

2 – is given if the baby is active and vigorous.

Respirations

This refers to an infant’s breathing effort and respiration.

If newborns aren’t breathing enough, or at all, they aren’t taking in enough oxygen to supply their muscles and organs.

0 – is given if there is no respiratory effort made

1 – scored if breathing is irregular or slow

2 – if the baby is breathing spontaneously and crying vigorously.

How common is a score of 10?

The majority of babies will make the transition from the womb to the outside world without complication. Interestingly, very few babies will score a perfect 10 on their Apgar test.

But don’t worry, it doesn’t mean anything is wrong with your baby. Apgar scores of 10 are actually quite rare.

Very few babies will be awarded a 10 on their one-minute Apgar score and only a few will score a 10 at 5 minutes. This is normal.

This is because most babies will lose at least one point for color, as their hands and feet usually remain blueish for a number of hours after birth.

This happens as your baby is adapting from receiving oxygen via the placenta, to having to use her own lungs for the first time.

In the first moments after birth, babies’ little bodies undergo some very complex physiological changes to make this happen.

As they adjust, the blood circulates to the most important parts of the body such as the brain and other organs. The hands and feet will get the lowest priority.

For more information see Why Do Babies Look Blue When They Are Born?.

What is a normal Apgar score?

A report published in collaboration with the American Academy of Pediatrics (AAP) defines 5 minute Apgar scores in a full-term infant as follows:

• Scores between 7 and 10 are classed as ‘reassuring’
• Scores between 4 and 6 are classed as ‘moderately abnormal’
• Scores between 0 and 3 are classed as ‘low’.

Apgar scores less than 7 mean there’s an increased risk of infection and breathing difficulties in newborns, as well as long-term conditions such as epilepsy and cerebral palsy.

The report considers a low Apgar score of between 0 and 3, at 5 minutes, is a non-specific sign of illness, possibly indicating a more serious condition relating to the brain.

What if my baby has low Apgar scores?

It’s important to remember most babies will achieve a reassuring Apgar score without any assistance at all.

According to the latest NHS Maternity Statistics, 98.6% of babies born after 37 weeks had an Apgar score of 7 or above, at 5 minutes.

This means only 1.4% of all babies born in the UK between 2019 and 2020 had an Apgar score defined in the ‘moderately abnormal’ or ‘low’ classification.

If your baby has a low Apgar score, a neonatal doctor, nurse practitioner or midwife will be on hand to ensure your baby receives all the care and immediate life-saving resuscitation efforts required.

Your baby might need nothing more than a little gentle encouragement to get all systems going, to bring up the Apgar score.

Some babies will require help to breathe. This could involve any level of resuscitation care – from basic to advanced.

You might like to read When Do Babies Take Their First Breath? for more information.

What can influence a newborn Apgar score?

There are many things that can influence a baby’s Apgar scores:

• Gestational age
• Maternal medications
• Maternal sedation or anesthesia
• Birth weight
• Congenital abnormalities
• Birth injury or trauma.

Limitations of the Apgar score

It’s important to recognize the Apgar scoring system can only be used as a tool.

The scores reflect an infant’s physiological wellbeing at one point in time, with the aim of identifying infants in need of immediate resuscitation following birth.

The test also has limitations.

Some elements of the scoring system are subject to user variability. For example, elements such as tone, color, and grimace reflexes may be scored differently, depending on who is performing the test.

These elements also differ depending on the gestation of the baby. For example, a healthy preterm baby with no evidence of asphyxia (lack of oxygen) is likely to score lower, based solely on physical immaturity.

The Apgar score alone shouldn’t be used to predict future health problems, or how a baby will do.

In summary, the Apgar test has become the global standardized method of assessing the physical status of all newborns, minutes after birth.

The majority of newborns transition smoothly without any help whatsoever, and will receive a reassuring Apgar score.

A tiny percentage of babies might require emergency interventions, but your health care team will be there to assess their needs, and arrange help if necessary.

In the meantime, don’t get too caught up with the number; just enjoy that beautiful baby of yours