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.
What Is The Apgar Scale?
The Apgar scale is a five-category test used to evaluate a newborn baby’s overall health. It’s a rough measure of whether or not the child requires immediate medical attention, taking pulse, respiratory rate, reflex response and skin coloration into account. Apgar is the standard method for assessing newborn health, used by physicians, nurses and EMTs the world over.
The test is performed twice in most delivery rooms, once at 1 minute after birth and a second time after five minutes. After a minute, the idea is to gauge how well the child handled the birth process (or “fetal-to-neonatal transition”), Medline Plus writes. The five-minute test evaluates how well the child is doing outside the womb.
How Apgar Scoring Works
Sometimes, physicians will repeat the Apgar test more than twice. In cases where resuscitation is required, the test can be administered over and over again, usually at intervals of five minutes, to see whether and how much the baby’s condition improves.
A child’s Apgar score is calculated based on five simple criteria:
- Appearance – skin color
- Pulse – heart rate (taken with a stethoscope or by feeling the umbilical cord)
- 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. When 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 refers to the amount of tension in a person’s muscles at rest.
How To Take 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 (chest compressions should begin immediately) | 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.
Interpreting An Apgar Score
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.
High Scores
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.
Medium Scores
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.
Low Scores
Apgar scores below 4 suggest that an infant requires immediate life-saving treatment. Children who score between 0 and 3 need to be resuscitated at once, or risk a tragic outcome. At the same time, children who require immediate resuscitation should be resuscitated immediately. There’s no sense in waiting for the Apgar test to be taken before jumping in to save an obviously-distressed child’s life.
In emergency circumstances, assigning an Apgar score can take more time than it’s worth. In the event of resuscitation, however, taking an Apgar score at five-minute intervals after each resuscitation attempt can be a helpful way of gauging whether or not the intervention is working.
This point is crucial for the purposes of medical malpractice. While it’s the standard of care to take an Apgar score at 1 and 5-minutes, it can also be the standard of care to forego taking the test, if a child obviously requires resuscitation and waiting for the test would simply delay a necessary 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.
The Link Between Apgar Scores & Cerebral Palsy
With that being said, recent research has opened up the possibility that Apgar scores could mean more. A relatively-large study from Sweden, published in the British Medical Journal on February 8, 2018, found a direct correlation between Apgar scores and two serious medical conditions: cerebral palsy and epilepsy.
The study looked at 1,221 Swedish children who had been diagnosed either with a cerebral palsy disorder or epilepsy, then compared their Apgar scores after birth to a group of children who had all received Apgar scores of 10 after five minutes.
The relationship was clear, the researchers say. As Apgar scores decreased, the risk of both cerebral palsy and epilepsy shot upwards. Children who received an Apgar score of 9 were around twice as likely to develop CP than children with scores of 10. A child who received an Apgar score of 0, on the other hand, was nearly 278-times more likely to develop the disorder.
That’s an enormous increase, and it was even more pronounced when the team looked at 10-minute Apgar scores. The link was less clear for epilepsy, but the study notes an increased risk for the seizure condition in children who received Apgar scores of 7 or less.
Don’t Obsess Over Apgar
Even so, parents shouldn’t over-interpret their child’s Apgar score. Just because a child is scored low at first doesn’t mean they have a permanent disorder. Many kids who score low on the Apgar scale at one minute reach normal levels after five minutes. And most children who receive low scores don’t go on to develop cerebral palsy or epilepsy.
In a broader sense, low Apgar scores do not mean that a child is unhealthy or will develop any medical conditions in the future. In the medical context, it simply means that the child might need a little more help at the beginning of his or her life. Likewise, a high Apgar scores, while certainly reassuring for parents, doesn’t predict a child’s long-term health.
