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Apgar Score

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Apgar Score System

The Apgar score system is used by doctors and nurses to evaluate infants one minute and five minutes after birth. Dr. Virginia Apgar developed this Apgar Score System in 1952 that provided a quick way to assess a newborn infant's clinical state at 1 minute of age and the need for immediate intervention to start breathing. In 1958, a second study was released, this time with a greater number of cases. After delivery, this scoring system provided a systematic examination for babies. The Apgar score is made up of five parts: colour, heart rate, reflexes, muscular tone, and breathing are all given a score of 0, 1, or 2 for each.

The Apgar scores are usually announced to the labour room by a nurse or doctor shortly after the baby is born. This allows all present medical workers to know how the infant is doing, even if some of the medical personnel are tending to the mother. When a parent hears these figures, they should understand that these are just one of several tests that medical providers will conduct. Heart rate monitoring and umbilical artery blood gases are two further examples. Assigning an Apgar score, on the other hand, is a quick technique to let people understand the baby's condition right after birth.

While the Apgar score is useful in assisting medical providers in determining how a newborn is doing immediately after birth, it usually does not influence a newborn's long-term health. The Apgar score is also subjective because it is assigned by a person. A newborn could receive a “7” from one person and a “6” from another. As a result, the Apgar score is simply one of the numerous tests used to measure a newborn's overall health.

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Apgar Full Form

When the scoring system became widely used, medical practitioners devised an acronym based on Apgar's surname to make each of the assessment's criteria easier to remember. The following are the five factors used to determine the Apgar score:

A – Appearance (Skin Colour)

This is an assessment of the infant's skin colour. If the infant is blue or pale all over, blue at the extremities, or pink all over, the medical team will take measures.

P – Pulse (Heart Rate)

The medical team determines whether the baby's heart rate is missing, slow (less than 100 beats per minute (bpm), or fast (more than 100 bpm) during this examination.

G – Grimace (Reflex Irritability/Response)

The medical team will ask if the baby has no response to stimulation, replies with a grimace, or responds by crying and pulling away during this exam.

A – Activity (Muscle Tone)

The medical team will ask if the infant is limp, if the infant has some flexion (joint movement), or if the infant has active motion during this examination.

R – Respiration (Breathing Ability)

During this procedure, the medical team determines whether the infant is having trouble breathing, has a faint cry and delayed breathing, or is breathing regularly and crying normally.

The Apgar score is calculated by adding these five criteria together. Scores range from ten to zero. The greatest possible score is ten, but only a few babies achieve it. Because most babies' hands and feet are blue until they have warmed up, this is the case.


The following technique is used in Apgar Score System to compute the score:

1. Breathing Effort

  • The respiratory score is 0 if the infant is not breathing.

  • The respiratory score is 1 if breathing is slow and irregular, weak, or gasping.

  • The respiratory score is 2 if the baby is crying a lot.

2. Heart Rate

  • Note that the most important aspect of the score in assessing the necessity for resuscitation is the heart rate, which is measured using a stethoscope.

  • The heart rate score is 0 if there is no heartbeat.

  • The heart rate score is 1 if the heart rate is fewer than 100 beats per minute.

  • The heart rate score is 2 if the heart rate is greater than 100 beats per minute.

3. Muscle Tone

  • The score for muscle tone is 0 if the muscle tone is loose and floppy without activity.

  • The muscle tone score is 1 if the infant shows some tone and flexion.

  • The score for muscle tone is 2 if the newborn is in active motion with a flexed muscular tone that resists extension.

4. Grimace Response or Reflex Irritability in Response to Stimulation

  • The reflex irritability response score is 0 if there is no response to a stimulus.

  • The reflex irritability response score is 1 if there is grimacing in response to a stimulus.

  • The reflex irritability reaction is 2 if the infant cries, coughs, or sneezes when stimulated.

5. Color

  • Because peripheral cyanosis is frequent among normal babies, most infants will receive a score of one for colour. In non-white infants, colour can often be deceiving.

  • The infant's colour score is 0 if he or she is pale or blue.

  • The score for colour is 1 if the infant is pink but the extremities are blue.

  • The colour score is 2 if the infant is totally pink.

Apgar Score Interpretation

A healthy infant is one who has a score of 7 or higher on the test. A lower score does not imply that your child is sick. It indicates that a baby may require emergency medical attention, such as airway suctioning or oxygen to help him or her breathe better. Even perfectly healthy babies can have a lower score than typical, particularly in the initial few minutes following birth.

It's not uncommon for babies to get a little low score (particularly at 1 minute):

  • after a high-risk pregnancy

  • through a C-section

  • after complicated labour and delivery

  • prematurely

The test is repeated 5 minutes after birth. If a baby's score was initially low and hasn't improved, or if additional concerns exist, the doctors and nurses will continue to provide any necessary medical care. The baby will be continuously monitored.

Many low-scoring newborns are completely healthy and adjust to life outside the womb just fine. The purpose of this test was not to predict a baby's long-term health, behaviours, intelligence, personality, or outcome. It was created to assist healthcare professionals in determining a newborn's general physical state in order to quickly determine whether the baby required immediate medical attention.

Normal Apgar Score

After five minutes, a score of 7 to 10 is considered "reassuring." “Moderately abnormal” is a score of 4 to 6.

As we have already discussed, a score of 0 to 3 indicates that something is wrong. It suggests a need for more intervention, usually in the form of breathing help. A parent may notice staff vigorously cleaning a youngster or administering oxygen through a mask. A doctor, midwife, or nurse practitioner may recommend that a patient be sent to a neonatal intensive care nursery for additional care.

The Apgar scoring system isn't perfect in the opinion of many doctors. The Combined-Apgar score is one example of a modification to this scoring system. This system not only describes the baby's Apgar score, but also the interventions that he or she has received. The Combined-Apgar score has a maximum of 17, indicating a newborn that has not had any interventions and has received all points. A 0 implies that the baby did not respond to interventions.

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.

Clinical Significance

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.


  • 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.


When appropriately administered, the Apgar score defines the newborn infant's condition soon after birth and serves as a tool for standardised testing. It also allows for the recording of the fetal-to-neonatal transition. Individual mortality or a negative neurologic outcome are not predicted by Apgar scores. Apgar values of less than 5 at 5 and 10 minutes definitely reflect an increased relative risk of cerebral palsy, according to population studies, and the degree of abnormality correlates with the risk of cerebral palsy. Cerebral palsy does not develop in the majority of infants with low Apgar scores. 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.

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FAQs on Apgar Score

1. What is Apgar Score?

Ans: The Apgar score is the most generally acknowledged and utilised technique for evaluating neonates, determining which newborns require resuscitation, and determining resuscitation success. Heart rate, respiratory effort, muscular tone, reflex irritability, and colour are the most important criteria in the score, with heart rate and respiratory effort being the most critical. A score of 0 to 2 is assigned to each variable, giving a total score of 10. As resuscitative operations continue, the Apgar score is evaluated at 1 and 5 minutes, then at 10 and 20 minutes. A newborn with a score of 0 to 3 is regarded as severely depressed, while a score of 7 to 10 is considered normal.

2. Does a Low Apgar Score Mean Medical Malpractice Occurred?

Ans: A low Apgar score does not always imply that there was medical negligence. Low Apgar scores, on the other hand, are frequently linked to birth damage, which may have resulted from medical malpractice. Furthermore, it may be considered carelessness if physicians fail to act on low Apgar scores and offer proper therapy. It is medical malpractice if damage occurs as a result of this negligence.

3. What is an Assisted Apgar Score?

Ans: Because the variables under consideration will alter during resuscitation, Apgar scores assigned during resuscitation cannot be correctly compared to scores from newborns who are breathing spontaneously. To account for the resuscitation, an "assisted" Apgar score must be applied in such circumstances.

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