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    APGAR Score

    Assesses neonates 1 and 5 minutes after birth.
    When to Use
    Why Use

    Perform on every live newborn, regardless of GA, at 1 and 5 minutes of life.

    • 60 seconds after complete delivery of the newborn was deemed the point of most marked depression.
    • Per Neonatal Resuscitation Program (NRP), scoring continues at 5 minute intervals until reaching a score of 7 or until 20 minutes of life is encountered.
    • Scored by any provider with direct patient contact at the specified time.
    • The APGAR Score was developed to provide a simple and reliable grading scheme of newborns to communicate effects of obstetrical practices, maternal analgesia, and resuscitative efforts.
    • 5 objective signs were chosen for easy determination without interfering in patient care.
    • It should NOT be used to predict individual risk of mortality and adverse neurologic outcome.
    • Gestational age (GA), maternal sedation, congenital malformations, trauma, inter-observer variability may affect APGAR scoring.
    • Convenient and validated method to report status of a newborn and response to resuscitation.
    • Simple to teach in the delivery room. 1958 Second Report used ratings of house officers, nurses, and medical/nursing students.
    • Reliable to use, as variability between independent raters was minimal.
    • Useful in preterm and term newborns.
    • Corroborated by biochemical lab data.
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    • The 5 criteria are not of equal significance. The original article noted that HR and respiratory effort were most important, while color was least important.
      • To improve ease and utility, the criteria were not weighted for item importance.
    • The 5 minute score is regarded as the better predictor of survival.
    • Multiple publications from the American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) since 1996 including “Use and Abuse of APGAR” have emphasized limitations of APGAR to identify birth asphyxia and neurologic prognosis.
      • Score of 0-3 at ≥5 minutes is nonspecific marker of illness, “which may be one of the first indications of encephalopathy” but is not specific for asphyxia (Pediatrics 2015).
      • Asphyxia is only considered with evidence of impaired intrapartum or immediate postpartum gas exchange based on clinical condition and lab data.
        • Non-reassuring fetal HR tracings, imaging studies, EEG tracings, placental pathology may aid diagnosis.
      • Scores of ≤5 at 5 minutes and 10 minutes are associated with increased population risk of cerebral palsy (20-100 fold) and poor neurologic outcome, respectively.
        • Such population risks should not be extrapolated for any individual.


    • Per NRP protocol, resuscitation should commence prior to 1 minute, so APGAR score should not dictate need for initial resuscitation or specific interventions.
    • A 2014 Neonatal Encephalopathy & Neurologic Outcome report defines 5 minute score of 7-10 as reassuring, 4-6 as moderately abnormal, and 0-3 as low.
    • If score is ≤5 at 5 minutes, obtain an umbilical artery (UA) blood gas.
    • 2015 ACOG/AAP publications and 2011 NRP reiterate that a score of 0 at 10 minutes may help decide whether continued resuscitative efforts are indicated due to poor prognosis.
    • Score during resuscitation is different than for a spontaneously breathing newborn.
      • Expanded score reporting during resuscitation is encouraged (Pediatrics 2015).


    Addition of assigned points.

    • 5 independent items, each scored 0 (Absent), 1 (Intermediate), or 2 (Present)
    • Minimum score = 0; maximum = 10
    • Initial testing for “Reflex Irritability” was nasal and oropharyngeal suctioning with rubber catheter meant to elicit grimace, sneeze, or cough.
      • Later, a rapid, tangential slap of the sole of the foot was found to be an easier and more effective stimulus.

    Facts & Figures

    Score interpretation:

    • Scores ≥7; generally normal
    • Score of 4 to 6; fairly low
    • Scores ≤3; critically low, needs intervention

    Evidence Appraisal

    • The original 1953 series included 1,021 newborns from a single hospital center.
    • The sample included all live singleton/twin neonates with birth weights >500 grams as a result of any spontaneous, instrument/surgically-assisted delivery using multiple anesthesia methods.
    • Two raters were used for each assessment point.
      • Despite no published measure of inter-rater reliability, variability between observers was only ±1 point.
      • Variation was most common in the mildly depressed range (i.e., 5-7).
    • To assess for score “accuracy”, the sample was subcategorized into 3 groups. Percent death by category was 14% with score 0-2, 1.1% death in those 3-7, and 0.13% with score 8-10.
      • Though intended to convey clinical status during a moment in time, the original article did make mention of prognosis.
    • Apgar’s Second Report in 1958 internally validated the scoring system and compared it to UA blood gas samples in >15,000 newborns.
      • Death rates were similar by score category to the initial paper.
      • Lower scores associated with “chemical findings characteristic of asphyxia…”
      • Concluded score was particularly beneficial in determining need for resuscitation.
    • The 2001 study validated the original measure on >150,000 mothers of singleton newborns born at >26 weeks GA.
      • In premature newborns, those with 5 minute APGAR scores of 0-3 had a relative risk of neonatal death of 59 (95% CI 40-87) compared to a score of 7-10. In term newborns, the RR was 1460 (95% CI 835-2555).
      • After accounting for GA, the lower 5 minute APGAR score was still significantly correlated with increased risk of neonatal mortality.
      • APGAR score was a better predictor of neonatal mortality than degree of acidemia on UA blood gas. Scores of 0-3 plus pH < 7.0 almost doubled the risk of neonatal mortality.
      • Scores of 0-3 was significantly correlated with early death (i.e., >24 hours of life) in all GAs.
      • In term infants with 5 minute scores of 0-3, RR of death by Hypoxic-Ischemic Encephalopathy was 13 (95% CI 3-58).


    Dr. Virginia Apgar

    About the Creator

    Virginia Apgar, MD, (d. 1974) was an obstetrical anesthesiologist. Her eponymous score was the first to rate baby health at the time of birth. Through work at the March of Dimes, she was the first to shine light on the problem of premature birth. She was the first woman to be named Full Professor at Columbia University’s College of Physicians and Surgeons and is famously credited as saying that “women are liberated from the time they leave the womb.”

    To view Dr. Virginia Apgar's publications, visit PubMed

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    Dr. Virginia Apgar
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