The APGAR Score

What is an APGAR?

• 1952: Dr. Virginia Apgar devised scoring system to assess rapidly clinical status of a newborn to determine if prompt intervention is required to establish breathing.

• Has subsequently stuck, and is reported at 1 minute and 5 minutes after birth for all infants

  • Continued at 5 minute intervals thereafter until 20 minutes for scores under 7.

• The score is eponymous for Dr. Apgar as well as an acronym.

• Each component of the score can receive 0, 1, or 2 points:

  • Appearance (color)

    • 2 points: normal over entire body

    • 1 point: normal except extremities (acrocyanosis)

    • 0 points: cyanotic/pale all over

  • Pulse

    • 2 points: HR >100

    • 1 point: HR < 100

    • 0 points: absent HR

  • Grimace (reflex irritability)

    • 2 points: sneeze, cough, or vigorous cry, active withdrawal of extremities to stimulus

    • 1 point: grimace, weak response to stimulus

    • 0 points: no response to stimulus

  • Activity (muscle tone)

    • 2 points: Active motion

    • 1 point: arms and legs flexed to some degree

    • 0 points: hypotonic, limp

  • Respirations

    • 2 points: Good effort, crying

    • 1 point: Gasping, irregular efforts, hypoventilation

    • 0 points: not breathing

• While the Apgar score is useful for conveying information about the infant status quickly, resuscitation needs to be started before the Apgar calculator intervals.

• The Apgar can be to some degree prognostic – an Apgar of 0 at 10 minutes have very few reports of infants surviving with normal neurologic outcomes, and it’s reasonable to consider discontinuing resuscitative efforts at that point.

• The five minute score is generally considered more useful/prognostic:

  • A score of 7-10 is considered reassuring

  • 4-6 is moderately abnormal

  • Under 4 is abnormal, especially in term and late-preterm infants

Limitations of the Apgar Score

• The score is one moment in time, and is subjective in some components

• Multiple factors can influence the score and make it more “false positive” with low scores, such as:

  • Maternal sedation/anesthesia

  • Congenital malformations or genetic abnormalities

  • Gestational age

• Biochemical disturbances such as fetal acidemia must be quite profound to affect the Apgar score

• A low score doesn’t predict morbidity or mortality for any individual infant, and cannot be used alone to diagnose asphyxia.

  • Cord gases should be obtained to demonstrate poor gas exchange and metabolic acidemia in order to truly diagnose asphyxia.

• Apgars are often continued to be assessed during resuscitation, but these are obviously not equivalent to scores assigned to spontaneously breathing infants

  • There is no standard for reporting Apgars after the start of postnatal resuscitation, because those interventions obviously affect the score. 

  • There are expanded Apgar score forms, where additional information regarding the infant’s resuscitation and response can be recorded to help assess the impact of interventions and the infant’s status in light of these.

    • Essentially like a “code sheet” for neonates

Outcomes after Apgar Scoring

• 1 minute Apgar scores don’t predict outcomes well at all

• 5 minute scores of 0-3 correlate with neonatal mortality in large populations, but are not individually good at predicting neurologic dysfunction for an infant.

  • Low Apgar scores do seem to correlate at population level with increased relative risk of cerebral palsy (20-100x higher risk with 0-3 versus 7-10 score).

  • Most infants with low Apgar scores do not go on to develop neurologic issues or CP.

• ACOG does recommend that a cord gas be sent for any 5 minute Apgar of less than 5, and considering sending placenta to pathology as well. 

• Apgars can also be useful to monitor for quality improvement programs to assess both obstetric and pediatric response and resuscitation.

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