Since its development in 1952, the Apgar score has become the leading method for evaluating a newborn’s overall health after birth. Created by Columbia-educated obstetric anesthesiologist Virginia Apgar, Apgar scores are now taken in delivery rooms throughout the world, allowing doctors and nurses to communicate quickly about an infant’s immediate medical needs.

Newborn Baby

How Apgar Scoring Works

Apgar scores are recorded twice, one minute and five minutes after a child’s birth. In cases where resuscitation is required, the test can be administered again, usually at intervals of five minutes. A child’s Apgar score is calculated based on five simple criteria:

  • Appearance – skin color
  • Pulse – heart rate (taken with stethoscope)
  • Grimace – reflex response
  • Activity – muscle tone
  • Respiration – breathing quality

Doctors assign points in each one of these categories, starting at 0 and reaching a maximum of 2. Once the points are added up, the child will be given a total Apgar score between 0 and 10. Lower scores indicate that a newborn may require medical attention. Higher scores generally suggest that an infant will require only routine care. Before figuring out how an Apgar score is calculated, let’s take a closer look at what some of these criteria are telling us about a child’s health.

Appearance

When body tissues that lie near the skin’s surface don’t get enough oxygen, they can turn blue, gray or extremely pale. This condition is known as cyanosis and could indicate a number of serious medical conditions. Researchers identify two main types of cyanosis, depending on the underlying problem:

  • Central cyanosis – blue or gray discoloration in the lips, tongue and trunk
    • blood isn’t receiving enough oxygen as it courses through the lungs
    • associated with a wide range of respiratory and circulatory conditions
  • Peripheral cyanosis – blue or gray discoloration in the limbs or fingers
    • blood isn’t circulating properly; it’s been blocked somehow
    • associated with respiratory and circulatory conditions, including blood clots

As we’ll see, the Apgar scale for skin coloration takes this critical distinction into account, assigning different point values to children with central and peripheral cyanosis.

Grimace

Healthy newborns react spontaneously to stimulation by grimacing, coughing, sneezing, crying or wailing. Wailing, as it turns out, is a very healthy response, as children clear their airways, which may still be filled with amniotic fluid. Where an obstetrician chooses to suction amniotic fluid out a newborn’s mouth and nostrils, the doctor can evaluate the infant’s response to this form of stimulation.

Activity

Healthy muscles are always slightly tense, which is how our bodies maintain a posture once we’ve occupied it. This baseline tension also allows our muscles to snap into action when necessary. Muscle tone always refers to the amount of tension in a person’s muscles at rest.

Taking An Apgar Score

Criteria 0 Points 1 Point 2 Points
Appearance entire body is blue or pale (central cyanosis) only extremities are blue (peripheral cyanosis) no cyanosis detected
Pulse no heartbeat fewer than 100 beats per minute greater than 100 beats per minute
Grimace no reaction to stimulation only grimacing grimacing and cough, sneeze or vigorous cry
Activity muscles appear loose and floppy; body is flaccid some muscle tension; limbs flex active motion
Respiration not breathing slow, uneven breathing crying

After birth, a child will be graded according to the point system we’ve described in the table above. The points from each category are added up, with a maximum of 10 total points. While medical professionals quibble on the details, most experts agree that a score of 7 or higher is perfectly normal and healthy. Children who fall into this group will usually require only routine post-delivery treatment.

A “perfect” score of 10 points is rare. At the least, most children will be born with mild cyanosis, which makes their limbs appear bluer than normal. That’s not usually something to worry about, but it will drop a healthy newborn’s score down a point.

Scores lower than 7, according to the National Library of Medicine, indicate that a child requires medical attention. Some babies will need to have their airways cleared out manually. Others will benefit from a little physical stimulation to increase their heart rate. After intervention, doctors will take the child’s Apgar score again to check for improvement. Most kids end up scoring much better on their second go-around. Infants who do not improve substantially will continue to be treated, with Apgar scores taken over the course of another 20 or so minutes.

Apgar scores below 4 suggest that an infant requires immediate life-saving treatment.

What Do Apgar Scores Mean?

Apgar scores can’t predict a child’s health issues in the long-term. As Dr. Kristen Montgomery notes in the Journal of Perinatal Education, many researchers have attempted to find a correlation between Apgar scores and chronic medical conditions, but these attempts have largely come up empty. Extremely-low scores (between 0 and 3 points) may be a sign of brain injury, but the Apgar score alone can’t diagnose anything. Apgar scores can’t tell you that a child will develop cerebral palsy or seizure disorders or any other specific medical condition. Apgar isn’t for diagnosis. It’s for gathering evidence that a newborn requires immediate medical attention.

Parents shouldn’t over-interpret their child’s Apgar score. Many kids who score low on the Apgar scale at one minute reach normal levels after five minutes. In a broader sense, low Apgar scores do not mean that a child is unhealthy or will develop any medical conditions in the future.