How is the Apgar Score Used To Assess Newborns?

The Apgar score is a test administered to newborns right after their birth. This test checks a newborn’s heart rate, muscle tone, and other signs to determine if the baby is in need of extra medical care or any emergency care is to be provided. The Apgar test is administered two times – once at one minute after birth and once at five minutes after birth. If there are certain concerns about the newborn’s condition, then the test might be administered again. Read on to learn more about how the Apgar score is used to assess newborns.

What is the Apgar Score?

The Apgar test or Apgar scoring system is used widely by doctors and nurses around the world to assess newborns after they are born. The test is administered twice – first at one minute after birth and then at five minutes after birth. The Apgar scoring system was created in 1952 by Dr. Virginia Apgar.(1,2)

In the Apgar test, five categories are used to check the overall health of a baby. Each category is scored by the doctors on a scale of 0 to 2, with a score of 2, meaning the child is in good health. The five categories are:(3)

  • Appearance (skin color of the newborn)
  • Pulse (heart rate of the newborn)
  • Grimace response (reflex of the newborn)
  • Activity (muscle tone of the newborn)
  • Respiration breathing rate and effort required to breathe

The Apgar score is used by doctors and nurses to quickly determine the status of a newborn’s health. Low Apgar scores are an indication that the newborn needs extra care. For example, the infant might need assistance with breathing.

Typically after birth, a doctor or nurse will announce the Apgar scores to the entire labor room. This allows all medical personnel present there to know the status of the baby’s health, even if some of the staff is attending to the mother.

While other diagnostic tests are also used to monitor the heart rate and umbilical artery blood gases, but the Apgar score is the quickest way to let all medical personnel understand the newborn’s condition immediately after delivery.(4)

Understanding How the Apgar Score Works

As mentioned above, the Apgar score has been divided into five categories, and each category has a score of 0 to 2 points. A perfectly healthy child should receive an overall Apgar score of 10. However, in the first few moments of life, it is rare to see a newborn score a 10. This is usually because many babies have blue feet or hands right after birth.

Here is a breakdown of how the Apgar score works:

  • A: Appearance (Skin Tone/Color)
  • 0 point: Blue, pale all over, or bluish-gray
  • 1 point: Body is pink, but extremities are blue
  • 2 points: Pink all over
  • P: Pulse or Heart Rate
  • 0 points: Heart rate is absent (no pulse)
  • 1 point: Heart rate is below 100 beats per minute
  • 2 points: Heart rate is regular (above 100 beats per minute)
  • G: Grimace Response (Response to stimulation)
  • 0 point: No response is present
  • 1 point: Facial movement is present, or grimace with stimulation
  • 2 points: Sneezing or coughing is present, withdrawal of foot with stimulation, crying, etc.)
  • A: Activity or Muscle Tone
  • 0 point: No movement is present, the baby appears limp or floppy
  • 1 point: Limbs are flexed
  • 2 points: Active movement is present
  • R: Respiration or Breathing Rate
  • 0 point: Breathing is absent
  • 1 point: Irregular or weak crying
  • 2 points: Good, strong cry is present

The Apgar scores are recorded at one minute and five minutes after birth. In some cases, the test may be repeated if needed. This is done because if the Apgar scores are low at one minute after birth, then the medical staff on duty will intervene, or the required interventions will be started.(5)

At five minutes after birth, the Apgar test is repeated to check if the baby has improved. If the score is still very low even after five minutes, then the medical staff will reassess the score after 10 minutes. In general, some babies are likely to have lower Apgar scores, such as:

  • Preterm babies(6)
  • Babies who have had a complicated delivery
  • Babies born through cesarean delivery(7)

What is a Normal Apgar Score?

According to the guidelines of The American College of Obstetricians and Gynecologists, an Apgar score between 7 to 10 taken five minutes after a baby is born is considered to be ‘reassuring’ or normal. A rating between 4 to 6 is considered to be ‘moderate abnormal.’(8)

A newborn with an Apgar score of 0 to 3 needs increased care and commonly also needs assistance in breathing. In such cases, it is usual for parents to see nurses drying off a baby vigorously or providing oxygen through a mask. In some cases, a doctor or nurse may also recommend transferring the baby to a neonatal intensive care unit for further medical care.

However, many doctors do not consider the Apgar testing system to be ideal.(9) There are already several modifications that have been made to the Apgar scoring system, including the Combined-Apgar score.(10) The Combined-Apgar scoring system also takes into account the interventions received by a newborn and not just the Apgar score.

A baby is graded on a maximums core of 17 in the Combined-Apgar test. The maximum score of 17 indicates a newborn who has not received any medical intervention upon being born and has received the maximum points in all categories. A score of 0, of course, indicates that the child failed to respond to any medical interventions.

Conclusion

There is no doubt that the Apgar score has proved to be invaluable in helping doctors determine how a newborn is doing right after delivery.

However, the Apgar score does not typically have any bearing on understanding how healthy a baby is in the long term. Furthermore, because a doctor assigns a numerical score, the Apgar test is, therefore, subjective. One doctor or nurse could score a baby as a 7, while another could score the baby as a 6 or an 8. This is why the Apgar score is just one of the many assessments and diagnostic tests that are used to evaluate a newborn’s overall health and condition.

References:

  1. Finster, M. and Wood, M., 2005. The Apgar score has survived the test of time. Anesthesiology: The Journal of the American Society of Anesthesiologists, 102(4), pp.855-857.
  2. Stuart, A., Olausson, P.O. and Källen, K., 2011. Apgar scores at 5 minutes after birth in relation to school performance at 16 years of age. Obstetrics & Gynecology, 118(2), pp.201-208.
  3. American Academy of Pediatrics, 2006. The Apgar score. Advances in neonatal care: official journal of the National Association of Neonatal Nurses, 6(4), p.220.
  4. Silverman, F.R.A.N.K., Suidan, J.O.S.E.P.H., Wasserman, J.E.A.N.N.I.E., Antoine, C.L.A.R.E.L. and Young, B.K., 1985. The Apgar score: is it enough?. Obstetrics and gynecology, 66(3), pp.331-336.
  5. Cnattingius, S., Norman, M., Granath, F., Petersson, G., Stephansson, O. and Frisell, T., 2017. Apgar score components at 5 minutes: risks and prediction of neonatal mortality. Paediatric and perinatal epidemiology, 31(4), pp.328-337.
  6. Hegyi, T., Carbone, T., Anwar, M., Ostfeld, B., Hiatt, M., Koons, A., Pinto-Martin, J. and Paneth, N., 1998. The Apgar score and its components in the preterm infant. Pediatrics, 101(1), pp.77-81.
  7. Kolås, T., Saugstad, O.D., Daltveit, A.K., Nilsen, S.T. and Øian, P., 2006. Planned cesarean versus planned vaginal delivery at term: comparison of newborn infant outcomes. American journal of obstetrics and gynecology, 195(6), pp.1538-1543.
  8. Acog.org. 2020. The Apgar Score. [online] Available at: <https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2015/10/the-apgar-score> [Accessed 6 April 2020].
  9. Rüdiger, M. and Konstantelos, D., 2015. Apgar score and risk of cause-specific infant mortality. The Lancet, 385(9967), pp.505-506.
  10. Dalili, H., Sheikh, M., Hardani, A.K., Nili, F., Shariat, M. and Nayeri, F., 2016. Comparison of the combined versus conventional Apgar scores in predicting adverse neonatal outcomes. PloS one, 11(2).