Apgar Score for Newborn Health Assessment

The Apgar score is a simple method to quickly assess the health of a newborn baby. This testing is non-invasive and involves observing the baby and checking in five categories over time: Appearance, Pulse, Grimace, Activity, and Respiration.

Dr. Virginia Apgar created the Apgar test in 1952. The five categories to assess a newborn come from her name.

Apgar testing is typically done at least twice after a baby is born. The first test occurs at 1 minute after birth, and the second happens 5 minutes after the birth. Medical staff may repeat the test at 10, 15, and 20 minutes if the score is low. 

The five criteria are each scored as 0, 1, or 2 (two being the best). The total score adds the five values together for a maximum of 10.

Apgar stands for Appearance, Pulse, Grimace, Activity, and Respiration. Medical teams use this scoring system to make sure babies are healthy right after birth. 

Each category is score 0, 1, or 2 points. The total is the baby’s Apgar score. A low score may indicate the baby requires medical intervention.

A – Appearance (skin color)

This is an evaluation of the baby’s skin color. 

• 2 points: The baby is pink all over
• 1 point: The baby’s extremities are blue or pale (blue hands and feet)
• 0 points: The baby is blue or pale all over

P – Pulse (heart rate)

During this evaluation, the medical team measures the baby’s heart rate.

• 2 points: A fast heart rate of more than 100 bpm
• 1 point: A slow heart rate of less than 100 beats per minute (bpm)
• 0 points: Heart rate is absent

G – Grimace (reflex irritability/response)

For the grimace response test, the medical team checks the baby’s response to stimulation.

• 2 points: the baby responds by crying and pulling away
• 1 point: the baby responds with a grimace
• 0 points: the baby does not respond

A – Activity (muscle tone)

To assess Activity, the medical team checks how much the baby moves around.

• 2 points: the baby shows active motion
• 1 point: the baby has some joint movement
• 0 points: the baby is limp and doesn’t move

R – Respiration (breathing ability)

The team checks how well the baby breathes.

• 2 points: the baby breathes well and cries normally
• 1 point: the baby has a weak cry and breathes slowly
• 0 points: the baby is failing to breathe

A baby that has trouble breathing may show signs of respiratory distress syndrome (RDS).

• Apgar scores of 0-3 are critically low, especially in term and late-preterm infants
• Apgar scores of 4-6 are below normal, and indicate that the baby likely requires medical intervention
• Apgar scores of 7 or higher are typically normal

Some components of the Apgar score are subjective. Sometimes, a baby requires urgent medical treatment despite having a high Apgar score.

A low Apgar score may indicate the baby needs intervention. The medical team should remain alert to the baby’s care needs. A baby with a low score is more likely than a baby with a high score to need resuscitation. In certain cases, medical staff may need to resuscitate a baby before determining the Apgar score.

Babies with low Apgar scores may need:

• care in the neonatal intensive care unit (NICU)
• resuscitation
• hypothermia therapy (cooling therapy) if the baby has HIE
• other preventative treatments for HIE and brain injury

According to the American College of Obstetricians and Gynecologists, a low one-minute Apgar score may not predict long-term health complications for the baby. Some babies with low Apgar scores at birth will grow up perfectly healthy after medical intervention.

Evidence suggests low Apgar scores at one minute and after five minutes may indicate problems. An infant with a low Apgar score after five minutes is much more likely to suffer long-term neurological damage.

A 2018 study in Sweden found that these babies had a greater risk for developing cerebral palsy (CP) and seizure disorders, such as epilepsy. Another study in the Journal of Clinical Sciences also found a significantly increased risk of cerebral palsy. This was especially true of children born at a normal birth weight.

A baby with a higher Apgar score can still have a brain injury like hypoxic-ischemic encephalopathy (HIE). In these cases, physicians must recognize other signs and symptoms of injury and treat them quickly.

What Can Cause Low Apgar Scores?

A wide range of pregnancy and birth-related complications can result in low Apgar scores.Babies with oxygen deprivation often perform poorly on the Apgar test. (However, higher scores do not necessarily indicate a baby received enough oxygen before birth. 

Some complications that can cause a baby to become oxygen-deprived include:

• Hypoxic ischemic encephalopathy (HIE)
• C-Section errors and delays
• Fetal monitoring errors
• Infections
• Maternal medical conditions
• Placental Abruption
• Preterm birth
• Prolonged and arrested labor
• Umbilical cord problems
• Uterine hyperstimulation/tachysystole (this can be caused by the delivery drugs Pitocin and Cytotec)
• Uterine rupture

If a child is showing signs of a brain injury after birth, medical staff must treat them promptly. 

A low Apgar score does not always mean that medical malpractice occurred.

Low Apgar scores often relate to birth injury. Birth injuries are often the result of medical malpractice. 

If physicians fail to deliver in time or fail to timely and correctly resuscitate with low Apgar scores, they may be negligent. Medical staff must provide the appropriate treatments to prevent harm to a baby with a low Apgar score. If injury occurs as a result of this negligence, it is medical malpractice.

An “assisted” Apgar score is a score assigned while medical professionals resuscitate a baby. Resuscitation changes what variables physicians look for when scoring a baby. A baby breathing on its own scores differently in the Apgar test.

The “assisted” Apgar score takes into account the resuscitation process. The American College of Obstetricians and Gynecologists (ACOG) recommends using an “expanded Apgar score report form.”

At the time Dr. Virginia Apgar began her career, women had great difficulty entering the field of medicine. In her case, that obscure specialty was anesthesiology. Apgar studied how anesthesia could impact mothers and babies.

One day, a medical student asked her how to evaluate the health of a newborn baby. She simply scribbled a list of what she considered to be the most important signs. Dr. Apgar combined those signs into a formal assessment tool to indicate whether a baby requires medical intervention. Apgar tested this method, and found it to be effective.