APGAR Score
The Apgar score is a rapid standardised assessment of the newborn's condition at 1 and 5 minutes after birth, designed to quantify the need for resuscitation and to evaluate the effectiveness of resuscitation efforts. It was developed by Dr Virginia Apgar, an American anaesthesiologist, and first published in 1952. The score evaluates five physiological parameters: Appearance (skin colour), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (breathing effort), each scored from 0 to 2, giving a total of 0-10. The mnemonic APGAR conveniently encodes the five parameters. A total score of 7-10 at 1 minute indicates a vigorous newborn requiring routine care only. A score of 4-6 indicates moderate depression and the need for resuscitative intervention, typically supplemental oxygen, tactile stimulation, and possibly positive pressure ventilation. A score of 0-3 indicates severe depression requiring immediate full resuscitation including airway management and chest compressions. The 5-minute Apgar score is more prognostically significant than the 1-minute score: a 5-minute Apgar of less than 7 is associated with increased risk of neonatal morbidity and mortality, and if it remains below 7 at 10 and 20 minutes, it is a criterion supporting the diagnosis of hypoxic-ischaemic encephalopathy (HIE) and eligibility for therapeutic hypothermia. Importantly, resuscitation should never be delayed to assign an Apgar score — it is an assessment tool, not a decision-making tool for initiating resuscitation in the birth room.
Apgar Score = Appearance(0-2) + Pulse(0-2) + Grimace(0-2) + Activity(0-2) + Respiration(0-2); Total 0-10; 7-10=Normal; 4-6=Moderate depression; 0-3=Severe depression; Assessed at 1 minute and 5 minutes; continue at 5-minute intervals if score <7
- 1Immediately after delivery, note the exact time of birth. Set a timer for 1 minute and 5 minutes for Apgar assessment.
- 2Assess Appearance (colour): 2 = pink all over; 1 = body pink but extremities blue (acrocyanosis — normal in first minutes); 0 = blue or pale all over (generalised cyanosis or pallor indicates poor perfusion).
- 3Assess Pulse (heart rate): 2 = ≥100 beats per minute; 1 = <100 bpm; 0 = absent. Use a stethoscope over the precordium or palpate the umbilical cord base for heart rate.
- 4Assess Grimace (reflex irritability): 2 = cough, sneeze, or vigorous cry in response to stimulation (suction, nasal catheter, or rubbing soles); 1 = grimace or weak cry; 0 = no response.
- 5Assess Activity (muscle tone): 2 = active flexion and spontaneous movement (flexed posture); 1 = some flexion; 0 = limp (no tone).
- 6Assess Respiration (breathing): 2 = strong cry, regular breathing; 1 = weak, irregular, or gasping respirations; 0 = absent.
- 7Sum all five components for total Apgar at 1 minute. Repeat at 5 minutes. If 5-minute score remains below 7, repeat every 5 minutes until 20 minutes of age. If ≥0-3 and not rapidly improving, escalate to full resuscitation. Document all scores and resuscitative interventions contemporaneously.
Acrocyanosis (blue hands/feet) is normal in the first minutes; recheck colour at 5 minutes
A score of 9 reflects a vigorous newborn. The single point deducted for acrocyanosis is expected and physiological in the first minutes of life. No resuscitation is required; dry, stimulate, and keep warm.
Initiate PPV at 40-60 breaths/min; reassess HR after 30 seconds; if HR <60 begin chest compressions
A score of 3 with HR 70 and absent tone requires immediate PPV. After 30 seconds of effective ventilation, reassess HR: if >100, continue support; if 60-100, check technique; if <60, add chest compressions.
Continue resuscitation; check blood gas; request neonatology; document all interventions
A 5-minute Apgar below 7 after resuscitation, particularly following an acute intrapartum event, is one of the criteria for evaluating therapeutic hypothermia eligibility for HIE. Document all interventions and scores at 5, 10, 15, and 20 minutes.
Improvement from 5 to 9 over 5 minutes is reassuring; document both scores; no further escalation
The 5-minute Apgar is more prognostically significant than the 1-minute score. Rapid improvement from 5 to 9 indicates the initial depression was transitional and expected — not indicative of significant HIE.
Birth room documentation of neonatal transition: Apgar at 1 and 5 minutes is a standard component of every birth record globally.. This application is commonly used by professionals who need precise quantitative analysis to support decision-making, budgeting, and strategic planning in their respective fields
Guiding escalation during neonatal resuscitation: serial Apgar scores communicate the baby's response to interventions between team members.. Industry practitioners rely on this calculation to benchmark performance, compare alternatives, and ensure compliance with established standards and regulatory requirements
HIE evaluation: 5-minute and 10-minute Apgar scores are key criteria for therapeutic hypothermia eligibility assessment.. Academic researchers and students use this computation to validate theoretical models, complete coursework assignments, and develop deeper understanding of the underlying mathematical principles
Medico-legal: Apgar scores are critical components of birth records used in litigation involving adverse neonatal outcomes.. Financial analysts and planners incorporate this calculation into their workflow to produce accurate forecasts, evaluate risk scenarios, and present data-driven recommendations to stakeholders
Epidemiology and research: population-level Apgar data is used to track birth outcomes, compare delivery units, and evaluate interventions across maternity services.. This application is commonly used by professionals who need precise quantitative analysis to support decision-making, budgeting, and strategic planning in their respective fields
Therapeutic Hypothermia Eligibility
An Apgar score ≤5 at 10 minutes is one of the National Institute of Child Health and Human Development (NICHD) criteria for evaluating HIE and therapeutic hypothermia eligibility. Additional criteria include pH <7.00 or base deficit ≥16 mmol/L on cord or early blood gas, and clinical signs of encephalopathy (seizures, abnormal tone, altered consciousness). All criteria must be assessed within 6 hours of birth for cooling to be initiated.
Apgar in Preterm Infants
In very preterm infants (<28 weeks), low Apgar scores are expected due to physiological immaturity and do not necessarily indicate intrapartum compromise or predict poor outcome in the same way as in term infants. The gestational age-adjusted Apgar score should be used, or at minimum, the score should be interpreted with explicit reference to gestational age.
Maternal Drug Effects
Magnesium sulfate given for pre-eclampsia or neuroprotection crosses the placenta and can cause neonatal hypermagnesaemia, manifesting as reduced tone and respiratory depression. These infants may have lower Apgar scores at 1-5 minutes requiring respiratory support but typically recover rapidly. Calcium gluconate is the antidote for neonatal magnesium toxicity.
Congenital Abnormalities
Newborns with chromosomal disorders (e.g., Trisomy 21, 18) or structural congenital abnormalities may have low Apgar scores due to inherent reduced tone or respiratory compromise from their underlying condition rather than intrapartum hypoxia. The Apgar score in these neonates must be interpreted in the context of the known diagnosis.
| Component | Score 0 | Score 1 | Score 2 |
|---|---|---|---|
| Appearance (colour) | Blue/pale all over | Blue extremities, pink body | Pink all over |
| Pulse (heart rate) | Absent | <100 bpm | ≥100 bpm |
| Grimace (response to stimulation) | No response | Grimace or weak cry | Cough, sneeze, vigorous cry |
| Activity (muscle tone) | Limp | Some flexion | Active, flexed limbs |
| Respiration | Absent | Weak, irregular, gasping | Strong cry, regular breathing |
Is the Apgar score used to decide when to start resuscitation?
No. Resuscitation decisions in the delivery room are based on rapid clinical assessment: Is the baby term? Is there good tone? Is the baby breathing or crying? Resuscitation must never be delayed to formally calculate the Apgar score. The Apgar is assigned retrospectively after the first minute and is a documentation and communication tool, not a real-time decision framework.
What does a 5-minute Apgar below 7 mean?
A 5-minute Apgar below 7 is associated with increased neonatal morbidity and mortality and may indicate significant intrapartum compromise. It is one criterion used to evaluate eligibility for therapeutic hypothermia (cooling therapy) for hypoxic-ischaemic encephalopathy. Continued resuscitation, blood gas analysis, and neonatology consultation are indicated. In practice, this concept is central to apgar score because it determines the core relationship between the input variables.
Can the Apgar score predict long-term neurological outcome?
A low Apgar score alone is not a reliable predictor of long-term neurological outcome. Approximately 75% of children who develop cerebral palsy had normal Apgar scores. Conversely, the majority of infants with low Apgar scores do not develop cerebral palsy. A sustained very low Apgar (below 3 at 10 minutes) in the setting of intrapartum compromise is more strongly associated with adverse outcome.
Does the Apgar score need adjustment for preterm infants?
Yes. Preterm infants routinely have lower Apgar scores than term infants due to expected physiological immaturity — reduced tone, irregular breathing, and acrocyanosis are normal findings in early gestation. A modified Apgar score for preterm infants (the Expanded Apgar or gestational age-adjusted interpretation) accounts for prematurity and avoids over-interpreting low scores as pathological in very preterm neonates.
What is the expanded Apgar score?
The expanded Apgar score, recommended by the American College of Obstetricians and Gynecologists, adds documentation of resuscitative interventions alongside each Apgar component score to provide a complete picture of the newborn's condition and the support provided. It replaces the standalone numeric score with a table showing both the score and the interventions at each time point.
Does maternal anaesthesia affect the Apgar score?
Yes. General anaesthesia with volatile agents can temporarily depress the newborn, causing reduced tone and respiration with lower Apgar scores at 1 minute. Epidural and spinal anaesthesia have minimal effect on Apgar scores when used correctly. Opioids given within 1-4 hours of delivery can cause transient neonatal respiratory depression that responds to naloxone.
What is the normal heart rate range used in Apgar scoring?
In Apgar scoring, a heart rate of 100 bpm or above scores 2 points. A heart rate below 100 bpm scores 1 point. An absent heart rate scores 0. The threshold of 100 bpm is used for scoring purposes; in clinical resuscitation, the key threshold is 60 bpm — below this, chest compressions should be started after 30 seconds of effective ventilation.
How is the Apgar score documented?
The Apgar score is documented as individual component scores plus the total at each time point (e.g., 1-minute Apgar: A1 P1 G1 A1 R1 = 5). Documentation should also include the time of birth, time of first breath, interventions performed, and personnel present. In the UK, all birth room documentation is part of the legal medical record and must be contemporaneous and accurate.
Pro Tip
Document Apgar scores alongside every resuscitative intervention performed, using the expanded Apgar format if available. A contemporaneous record of 'oxygen given', 'PPV 30 seconds', 'compressions started at 90s' alongside each Apgar component is far more informative clinically and medico-legally than a bare number.
Did you know?
Virginia Apgar was the first woman to be appointed a full professor at Columbia University College of Physicians and Surgeons. She developed her eponymous score in 1952 to give delivery room staff a practical, reproducible tool to assess newborns at a time when neonatal resuscitation was poorly standardised. The clever backronym — Appearance, Pulse, Grimace, Activity, Respiration — was proposed by Dr Joseph Butterfield in 1962 to help medical students remember the five components, and has ensured that her name has been committed to memory by generations of healthcare professionals worldwide.
References
- ›Apgar V. A proposal for a new method of evaluation of the newborn infant. Curr Res Anesth Analg 1953.
- ›American Academy of Pediatrics — The Apgar Score. Pediatrics 2015.
- ›Newborn Life Support 4th Edition — Resuscitation Council UK. 2021.
- ›Casey BM et al. The continuing value of the Apgar score for the assessment of newborn infants. NEJM 2001.